Inside This Issue: Latest U.S. HIV surveillance data; access to HIV testing, prevention, and care; new PrEP access program; World AIDS Day statements; funding opportunities; and more.
U.S. HIV Epidemic
Annual HIV Diagnoses Remain Relatively Stable Overall in U.S., But Some Groups See Significant Changes
The U.S. Centers for Disease Control and Prevention (CDC) recently published Diagnoses of HIV Infection in the United States and Dependent Areas, 2018 (Preliminary), which includes data on the number and rates of HIV diagnoses during the period from 2013 through 2017, as well as preliminary data for 2018. In this In Brief issue, we provide a detailed summary of this surveillance report, because it provides extensive information about the current state of the U.S. HIV epidemic. We hope this summary will be helpful for providers of HIV services, their patients and clients, and other persons interested in trends in the epidemic and in raising awareness about HIV/AIDS.
The report includes breakdowns by age, race/ethnicity, sex, transmission category, and region. Please note: In its analysis of trends in the data, CDC generally considered changes of less than 5% as “stable” and larger changes as either increases or decreases. In the summary below, we follow that same approach. For diagnosis rates, all figures are per 100,000 population.
Annual HIV Diagnoses
Overall U.S. and Regional Data: The annual rate of HIV diagnoses in the U.S. per 100,000 population decreased from 12.5 in 2013 to 11.8 in 2017, with a preliminary figure of 11.4 in 2018. During this period, the annual number of new HIV diagnoses remained relatively stable at around 38,000 to 40,000. Although diagnosis rates decreased in every region of the country during the period, there remained substantial differences among the regions. In 2018, the diagnosis rate in the South (15.7) was more than twice that in the Midwest (7.2), while rates in the Northeast (10.0) and West (9.3) where between those figures.
Age: The highest HIV diagnosis rates in 2018 were among young adults 25 to 29 years old (32.5 in 2018) and 20 to 24 years old (27.6). The diagnosis rates for most age groups were either stable or decreased during the period. However, rates increased among adults aged 25 to 29 and 30 to 34.
Race/Ethnicity: Significant racial/ethnic disparities in annual HIV diagnosis rates remained throughout the period – with the rate among Blacks/African Americans (39.3) about eight times higher than that in Asian Americans (4.7) and Whites (4.9) during 2018. In that year, Hispanics/Latinos had the second highest HIV rate (16.2), followed by persons of multiple races (12.4), Native Hawaiians and other Pacific Islanders (11.8), and American Indians/Alaska Natives (7.8). For the period 2013 through 2017, HIV rates increased among American Indians/Alaska Natives and Native Hawaiians and Other Pacific Islanders. Rates remained relatively stable for Asian Americans and Hispanics/Latinos. HIV rates among all other racial/ethnic groups decreased during the period.
Sex: Although overall HIV diagnosis rates decreased among both males and females during the period, they remained more than four times higher among males than among females in 2018 – 22.5 versus 5.1. In that year, males accounted for 81% of all HIV diagnoses among adults and adolescents.
Transmission Category: Please note that CDC breaks down its transmission category data by sex. In addition, since the precise number of persons in each transmission category is unknown, the transmission category breakdowns include data only on the number of diagnoses and not diagnosis rates. Among male adults and adolescents during the period from 2013 through 2017, the annual number of diagnosed HIV infections decreased in the following transmission categories: heterosexual contact; and male-to-male sexual contact and injection drug use. The number of diagnosed infections attributed to male-to-male contact alone (not combined with drug use) remained stable, as did the number of infections attributed to injection drug use alone.
Among female adults and adolescents, the number of diagnosed infections attributed to heterosexual contact decreased between 2013 and 2017, while the number attributed to injection drug use was stable. In 2018, heterosexual contact accounted for 85% of all new HIV diagnoses among female adults and adolescents, while injection drug use accounted for 14%.
In 2018, among all adults and adolescents, diagnosed infections attributed to male-to-male sexual contact (70%, including 3% male-to-male sexual contact and injection drug use) plus those attributed to heterosexual contact for both males and females (24%) accounted for the vast majority of diagnosed HIV infections in the U.S.
During the period from 2013 through 2017, both the number and rate of persons living with diagnosed HIV infection in the U.S. increased. By the end of 2017, 1,003,782 persons in the U.S. were living with diagnosed HIV infection. The prevalence of diagnosed HIV infection was 308.7 per 100,000 population.
Total Number of People Living with HIV by Race/Ethnicity: Blacks/African Americans accounted for 414,747 (41.4%) of all persons living with diagnosed HIV infection at the end of 2017, Whites for 300,619 (30.0%), Hispanics/Latinos for 222,662 (22.2%), persons of multiple races for 46,857 (4.7%), Asian Americans for 14,244 (1.4%), American Indians/Alaska Natives for 3,032 (0.3%), and Native Hawaiians and other Pacific Islanders for 839 (0.1%).
Prevalence Rates (per 100,000) by Race/Ethnicity: At the end of 2017, Blacks/African Americans had the highest prevalence rates (1,022.0), followed by persons of multiple races (675.9), Hispanics/Latinos (379.3), Whites (152.1), Native Hawaiians and other Pacific Islanders (146.5), American Indians/Alaska Natives (126.2), and Asian Americans (78.1).
HIV Prevalence by Sex: At the end of 2017, a total of 765,129 adult and adolescent males and 236,589 adult and adolescent females were living with HIV. In addition, 2,064 children under 13 years old were living with the virus. The corresponding HIV prevalence rates per 100,000 in these groups were 574.4 for adult and adolescent males, 169.9 for adult and adolescent females, and 3.9 for children.
HIV Prevalence by Transmission Category: Gay, bisexual, and other men who have sex with men (MSM) accounted for about 61% of the persons living with diagnosed HIV infection at the end of 2017. Male-to-male sexual contact accounted for 554,159 (55.3%) of the total, and male-to-male sexual contact combined with injection drug use accounted for an additional 55,318 (5.5%). About one-quarter (25.8%) of all persons living with HIV were infected through heterosexual contact. Of the 258,162 persons infected in this way, 180,137 (18.0% of the total persons diagnosed) were females and 78,025 (7.8% of the total persons diagnosed) were males.
A total of 119,244 persons (11.9%) living with HIV in the U.S. at the end of 2017 were infected through injection drug use (not counting the persons infected through male-to-male sexual contact plus injection drug use already covered above). Of this total, 69,956 (7.0%) were males and 49,288 (4.9%) were females. Perinatal infection was the transmission category for 10,007 persons (1.0%) currently living with HIV. Other modes of transmission were cited for an additional 4,827 persons (0.5%).
AIDS Diagnoses and Deaths
Stage 3 (AIDS) Diagnoses: Both the annual number and rate of Stage 3 (AIDS) diagnoses decreased from 23,660 (7.5 per 100,000) in 2013 to a preliminary figure of 17,032 (5.2 per 100,000) in 2018. The cumulative number of people diagnosed with AIDS from the beginning of the epidemic (including persons who have died) exceeded 1.25 million by the end of 2018.
Annual Deaths Among Persons with Diagnosed HIV Infection: In the U.S., for the period 2013 to 2017, both the total number of deaths and the death rate (from all causes) among persons with diagnosed HIV infection remained nearly stable, averaging approximately 16,500 per year (about 5.0 per 100,000). In 2017, 71% of these deaths occurred among people age 50 or older. Please note that these figures include all deaths (both HIV-related and non-HIV-related) among all persons living with diagnosed infection, including people in all stages of HIV disease. In the U.S. since the start of the HIV epidemic, the cumulative number of deaths among persons who ever had an AIDS diagnosis reached nearly three-quarters of a million (740,377) by the end of 2017.
Access to Prevention and Care
CDC: HIV Testing, Treatment, and Prevention Not Reaching Enough Americans
“Far too many Americans with HIV are unaware that they have it. Far too few have the virus under control through effective treatment. And far too few Americans are taking the daily pill that prevents HIV,” according to a CDC summary of its newly published Vital Signs report on HIV testing, viral suppression, and pre-exposure prophylaxis (PrEP). Key findings of the report are summarized below.
New HIV Infections, Diagnoses, and Transmission: Since 2013, progress in reducing the number of new human immunodeficiency virus (HIV) infections has stalled at approximately 38,000 new infections occurring each year.
Of the estimated 1.2 million persons living with HIV in the U.S. during 2017, only about 85.8% had a laboratory-confirmed HIV diagnosis. Persons who have undiagnosed HIV infection account for nearly four in ten (38%) of all new HIV infections.
Approximately 43% of new HIV infections are transmitted from persons who have received a diagnosis but are not receiving HIV medical care, and 20% of new HIV infections are transmitted from persons receiving medical care for HIV, but who are not virally suppressed.
Viral Suppression: Among persons diagnosed with HIV, less than two-thirds (62.7%) had a suppressed viral load in 2017. The age, racial/ethnic, and transmission risk groups with the lowest percentages of persons with viral suppression were those aged 13–24 years (56.9%), Blacks/African Americans (57.4%), and males who inject drugs (52.0%).
PrEP Coverage: PrEP is highly effective in preventing acquisition of HIV infection, and PrEP coverage has increased in recent years. Nevertheless, PrEP coverage remained low in 2018 – with less than one in five (18%) of the 1.2 million persons who are considered candidates for PrEP receiving it. In 2018, PrEP coverage was three times as high among males (20.8%) as among females (6.6%). Young persons aged 16 to 24 years had the lowest PrEP coverage rate (11.4%) of any age group. PrEP coverage was also much lower among Blacks/African Americans (5.9%) and Hispanics/Latinos (10.9%) than among Whites (42.1%).
“These findings confirm substantial gaps in diagnosing, treating, and preventing HIV infection and underscore the need for expanded efforts,” according to CDC. The targets for the proposed Ending the HIV Epidemic initiative are at least 95% of persons with HIV infection having received a diagnosis, 95% of persons with diagnosed HIV infection having a suppressed viral load, and 50% of persons with indications for PrEP having been prescribed PrEP.
“Accelerated efforts to diagnose, treat, and provide PrEP while addressing disparities, are urgently needed to reach the targets for the Ending the HIV Epidemic: A Plan for America initiative,” according to the report. “These accelerated efforts, along with other prevention strategies such as quickly responding to increases in diagnoses of HIV infections, will be needed to meet the ambitious U.S. goal of at least a 90% reduction in the number of new HIV infections by 2030.”
HHS Launches Ready, Set, PrEP Program
As noted in the article above, although PrEP is highly effective in preventing HIV transmission in persons at relatively high risk for HIV infection, less than 20% of the estimated 1.2 million candidates for PrEP were receiving it in 2018. There are also substantial disparities in PrEP coverage between males and females, among racial/ethnic groups, and among age groups. Many people still do not know about PrEP medications or how PrEP can help them, and many others cannot afford to pay for the medicine.
To help overcome these barriers and increase PrEP use, the U.S. Department of Health and Human Services (HHS) recently launched the national Ready, Set, PrEP program. To qualify for the program, participants must test negative for HIV, receive a valid prescription from a healthcare provider, and not have prescription drug coverage.
CVS Health, Walgreens, and Rite Aid have agreed to donate their dispensing services to HHS for the new program. Beginning no later than March 30, 2020, qualified patients will be able to obtain PrEP medications free of charge at the more than 21,000 CVS Health, Walgreens, and Rite Aid locations throughout 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands or through mail order. These pharmacies will also provide patient counseling and take steps to promote patient adherence to the PrEP regimen.
If someone thinks PrEP medications are right for them, they can talk with a healthcare professional or find a healthcare provider using the HIV.gov Provider Locator. People can find out whether they qualify and enroll in the program by visiting GetYourPrEP.com, or calling 855-447-8410.
The Global Epidemic
2019 World AIDS Day Commemorations Highlight Communities’ Role in HIV/AIDS Response
On Sunday, December 1, millions of people around the globe commemorated the 2019 World AIDS Day (WAD). The theme for this year’s observance was “Ending the HIV/AIDS Epidemic: Community by Community.” To mark the day, many government and public health leaders made statements offering their perspectives on the current state of the epidemic, as well as the challenges and opportunities ahead. In this news brief, we provide highlights from the 2019 WAD message of Winnie Byanyima, UNAIDS executive director. We also link to a selection of other WAD statements for your review.
“Communities are the best hope for ending AIDS, because communities have fought against HIV right from the beginning!” Winnie Byanyima noted in her WAD message. “As the epidemic raged through our countries, cities, and villages, women held communities together and bore the higher burden of care for their families . . . In the face of adversity, communities of gay men, sex workers, and people who use drugs have organized themselves to claim their right to health as equal citizens.”
“On World AIDS Day, UNAIDS salutes the achievements of activists and communities in the struggle against HIV. We remember and we honor all those whom we have lost along the way. Activists challenged the silence and brought life-saving services to their communities,” Byanyima said. “But the countless contributions by women and many others can never replace the responsibility of governments . . . With communities in the lead and governments living up to their promises, we will end AIDS.”
Here are links to a selection of other WAD statements and blog posts:
- U.S. Presidential Proclamation on World AIDS Day, 2019
- Statement from Alex Azar (Secretary, HHS)
- Statement from Rear Admiral Michael Weahkee (Deputy Director, Indian Health Service)
- SAMHSA Reaffirms Commitment to Ending HIV Epidemic with Support from Partners (Substance Abuse and Mental Health Services Administration)
- World AIDS Day 2019 Update from Robert Redfield (Director CDC)
- World AIDS Day 2019 Ending the HIV/AIDS Epidemic: Community by Community (Deborah Birx, State Department & Brett Giroir, HHS)
- Statement from U.S. National Institutes of Health
- Communities Uniting Against HIV (The Global Fund)
- Honoring Active Young Thrivers and Long-Term Survivors on World AIDS Day (AIDS United)
- Generation Now Responds (AVAC)
- We Won't Meet the 2020 AIDS Targets. Now What? (AVAC)
New HIV Funding Opportunities from HRSA
The Health Resources and Services Administration (HRSA) recently released four Notices of Funding Opportunity (NOFO) in support of the Ryan White HIV/AIDS Program (RWHAP) HIV care system. These funding opportunities include:
AIDS Education and Training Center National Clinician Consultation Center (HRSA-20-072), “to provide immediate expert consultation to health care professionals on HIV prevention, care, and treatment including diagnosis, testing, antiretroviral therapy, pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), perinatal HIV management, hepatitis B and C virus HIV coinfections, and behavioral health management for people with HIV.” Application due date: January 13, 2020.
Data Integration, Systems, and Quality (DISQ) Technical Assistance (HRSA-20-070), “to provide onsite and virtual technical assistance to RWHAP recipients and subrecipients to increase data-related capacity and improve the ease, completeness, timeliness, and accuracy of program data.” Applications due date: January 22, 2020.
TargetHIV (HRSA-20-094), “to serve RWHAP recipients, subrecipients, and HIV providers by providing readily accessible, up-to-date T/TA tools and resources through a web-based platform.” Application due date: January 22, 2020.
Rapid Antiretroviral Therapy (ART) Start in the Ryan White HIV/AIDS Program – Dissemination Assistance Provider (HRSA-20-076). This three-year SPNS initiative will fund a single organization “that will develop a compendium of promising rapid ART interventions.” Application due date: March 3, 2020.
HHS Updates Opportunistic Infection Guidelines & Seeks Nominations for Adult Antiretroviral Treatment Guidelines Panel
HHS recently updated the Talaromycosis section of its Adult and Adolescent Opportunistic Infections Guidelines. The revisions include changes in the recommendations regarding which patients should receive primary prophylaxis for talaromycosis and the drugs that should be used for prophylaxis, as well as detailed guidance on the course of therapy for patients with talaromycosis.
HHS also recently announced that its Panel on Antiretroviral Guidelines for Adults and Adolescents is also accepting nominations for both scientific/clinical members and community members of the panel. Candidates for scientific/clinical positions on the panel should have expertise in: HIV clinical research and clinical care; clinical pharmacology (with emphasis on expertise in antiretroviral-related drug-drug interactions); and clinical nursing in HIV. The selected scientific/clinical panel members will be responsible for critically evaluating new information and preparing guideline revisions.
According to HHS, candidates for community member positions on the panel should have knowledge of, and involvement in, issues related to the management of adults and adolescents living with HIV, as evidenced by experience in HIV treatment education/advocacy or clinical/public policy initiatives related to HIV treatment.
Persons chosen for the panel – whether as scientific/clinical members or community members – will serve a 4-year term beginning May 2020, with the potential for reappointment for an additional term. Self-nominations are welcome. Each nomination should include a resume and a letter of nomination or a letter of interest that specifically references how the nominee would contribute to the work of the panel. Supporting documents should be submitted to Alice Pau electronically (firstname.lastname@example.org) no later than January 10, 2020.
New and Updated Reports and Publications from CDC
In recent weeks, CDC has published several new and updated resources on its web pages. These publications, together with links and brief descriptions, are listed below.
Basic Statistics – This web page provides a brief summary of CDC’s latest HIV surveillance statistics in question-and-answer format, including preliminary data for 2018.
Epidemiology of HIV Infection 2018 (Preliminary) – This 35-slide set summarizes key data from the recent report, Diagnoses of HIV Infection in the United States and Dependent Areas, 2018 (preliminary), described in detail in the first feature of this issue of In Brief. The slides include breakdowns of new diagnoses, AIDS cases, and numbers of persons living with diagnosed HIV by race/ethnicity, sex, age, transmission category, and by state/territory of residence.
Maps Based on Data from 2018 HIV Surveillance Report (Preliminary) – This publication summarizes the new 2018 U.S. Surveillance data in 21 maps.
HIV and Coinfections – This fact sheet focuses on several common infections seen in people living with HIV: viral hepatitis (hepatitis A, B, and C) and tuberculosis. Information is provided on new diagnoses, prevalence, prevention, and treatment of these coinfections.
Status of HIV Case-Based Surveillance Implementation – 39 U.S. PEPFAR-Supported Countries, May-July 2019 – According to this report, of the 39 surveyed countries supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), 20 had implemented case-based surveillance, 15 were planning implementation, and four were not planning implementation. The report discusses challenges to implementation and the need to address policy barriers and gaps in technical infrastructure.