Abstract
Objective:
To evaluate HIV care continuum trends over time among women with HIV (WWH).
Design:
The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States.
Methods:
We used 2015– 2019 MMP data collected from 5139 adults with diagnosed HIV infection who identified as cisgender women. We calculated weighted percentages with 95% confidence intervals (CIs) for all characteristics and estimated annual percentage change (EAPC) and the associated 95% CI to assess trends. EAPCs were considered meaningful from a public health perspective if at least 1% with P values less than 0.05.
Results:
Among cisgender women with diagnosed HIV infection during 2015–2019, 58.8% were Black or African American (95% CI 54.4–63.3), 19% were Hispanic/Latina (95% CI 14.7–23.2), and 16% were Non-Hispanic White (95% CI 14.1–17.9) persons. There was a meaningful increase in the percentage who ever had stage 3 HIV disease from 55.8% (95% CI 51.0– 60.5) in 2015 to 61.5% (95% CI 58.1–64.8) in 2019 (EAPC 1.7%; CI 1.5–1.9; P < 0.001). There were no meaningful changes over time among women, overall, in retention in care, antiretroviral therapy (ART) prescription, ART adherence, missed appointments, or recent or sustained viral suppression.
Conclusion:
The HIV care continuum outcomes among WWH did not meaningfully improve from 2015 to 2019, raising a concern that Ending the HIV Epidemic in the US (EHE) initiative goals will not be met. To improve health and reduce transmission of HIV among WWH, multifaceted interventions to retain women in care, increase ART adherence, and address social determinants of health are urgently needed.
Keywords: cisgender women, HIV, HIV care continuum, HIV care outcomes, women with HIV
Introduction
Approximately 1.2 million people in the United States have HIV infection (PWH) with 35 000 new HIV infections occurring annually [1]. Although new diagnoses of HIVamong cisgender women (hereafter referred to as women) have declined in recent years, women still account for almost 20% of new HIV diagnoses in the United States [1]. In addition, because of longstanding systemic inequities, marked racial disparities among women persist – 73% of new HIV infections among women occurred in Black/African American (55%) and Hispanic/Latina (18%) women [1]. Compared with all people with diagnosed HIV infection, women also have lower viral suppression rates [1].
The National HIV/AIDS Strategy (NHAS) prioritizes efforts to reduce disparities and improve HIV outcomes among populations disproportionately affected by HIV, including Black women [2]. The NHAS seeks to reduce the overall number of new HIV infections by 90% and to increase viral suppression among Black women with diagnosed HIV infection to 95% from a baseline of 59.3% by 2030 [2]. Although some progress has been made toward these national prevention goals, gaps remain.
Improving the overall health of women with HIV (WWH) is a public health priority in the NHAS and Ending the HIV Epidemic in the US (EHE) initiative [2,3]. However, women are often not the focus of HIV-related research. Limited published reports have addressed recent disparities along the continuum of care among women [4]. This article seeks to evaluate HIV care continuum trends over time among WWH. These data could ultimately help inform EHE’s efforts and move the nation closer to meeting HIV prevention and care goals for all people with HIV, regardless of race/ethnicity or gender.
Methods
Study design and population
MMP is a national surveillance system that collects annual, cross-sectional data on social determinants of health and behavioral and clinical characteristics of adults 18 years or older in the United States and Puerto Rico [5]. MMP used a two-stage sampling method in which, during the first stage, 16 states and 1 territory were sampled from all US states, the District of Columbia, and Puerto Rico. During the second stage, simple random samples of persons with diagnosed HIV infection aged 18 years and older were drawn for each participating state/territory from the National HIV Surveillance System (NHSS), a census of persons with diagnosed HIV infection in the United States.
We analyzed data from the available MMP cycles (2015–2019); data were collected from the beginning of June of each cycle through the following May. Trained interviewers administrated standardized face-to-face or telephone interviews, and medical records at the participant’s most frequent source of HIV care were abstracted. Data were weighted based on known probabilities of selection at state or territory and person levels. Data were also weighted to adjust for nonresponse and poststratified to known population totals by age, race/ethnicity, and sex at birth from NHSS following established methods. All sampled states and the sampled territory participated. Response rates at the person-level varied by year: 40% in 2015, 44% in 2016, 46% in 2017, 45% in 2018, and 45% in 2019. Jurisdictions received approval from their local institutional review boards, and informed consent was obtained from all participants.
Participant characteristics, demographics, and clinical outcomes
Demographic characteristics, social determinants of health, and behavioral characteristics of participants were self-reported during the interview. Demographic factors and social determinants of health included education level, homelessness, incarceration, intimate partner violence (IPV), and household income at or below federal poverty guidelines. Health behaviors and outcomes included current cigarette smoking, binge drinking in the past 30 days, any injection or noninjection drug use, symptoms of major or other depression, and symptoms of generalized anxiety disorder in the past 2 weeks (definitions in Table 1) [6,7]. All characteristics were ascertained based on the past 12 months unless otherwise indicated. Clinical characteristics included medical record documentation during the past 12 months of retention in care, antiretroviral therapy (ART) prescription, ART adherence, one or more missed appointments, viral suppression at most recent test, and sustained viral suppression (definitions in Table 2) [8].
Table 1.
Selected demographic, social determinants of health and behavioral health characteristics of women diagnosed with HIV by year – Medical Monitoring Project, United States 2015–2019.
| 2015–2019 |
2015 |
2016 |
2017 |
2018 |
2019 |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Characteristicsa | n | Col % (95% CI) | n | Col % (95% CI) | N | Col % (95% CI) | n | Col % (95% CI) | n | Col % (95% CI) | n | Col % (95% CI) | EAPC | P value |
| Overall | 5139 | 967 | 1045 | 1037 | 1048 | 1042 | ||||||||
| Country at birth | ||||||||||||||
| United States | 4372 | 85.5 (83.7–87.2) | 820 | 84.9 (80.6–89.2) | 881 | 85.2 (80.9–89.6) | 882 | 86.3 (82.8–89.9) | 892 | 85.4 (82.1–88.6) | 897 | 85.4 (81.5–89.3) | 0.1 (−0.0 to 0.3) | 0.088 |
| All other countries | 720 | 14.5 (12.8–16.3) | 136 | 15.1 (10.8–19.4) | 151 | 14.8 (10.4–19.1) | 142 | 13.7 (10.1–17.2) | 148 | 14.6 (11.4–17.9) | 143 | 14.6 (10.7–18.5) | −0.7 (−1.0 to −0.4) | <0.001 |
| Length of time since HIV diagnosis | ||||||||||||||
| <5 years | 602 | 11.8 (10.7–12.8) | 134 | 13.5 (11.3–15.6) | 122 | 11.9 (9.7–14.0) | 118 | 11.3 (9.1–13.4) | 120 | 12.6 (10.2–15.0) | 108 | 9.7 (7.2–12.2) | −5.6 (−5.9 to −5.2) | <0.001 |
| 5–9 years | 906 | 18.6 (17.1–20.1) | 207 | 23.3 (18.6–28.0) | 212 | 20.8 (17.7–24.0) | 173 | 17.2 (13.5–20.8) | 165 | 15.8 (13.7–17.9) | 149 | 16.1 (13.6–18.7) | −9.9 (−10.1 to −9.6) | <0.001 |
| ≥10 years | 3622 | 69.6 (67.9–71.4) | 623 | 63.3 (58.6–67.9) | 707 | 67.3 (63.6–70.9) | 744 | 71.6 (67.5–75.6) | 763 | 71.6 (68.8–74.4) | 785 | 74.1 (70.9–77.3) | 3.8 (3.7–4.0) | <0.001 |
| Race/ethnicity | ||||||||||||||
| White, non-Hispanic | 751 | 16.0 (14.1–17.9) | 132 | 15.8 (11.1–20.5) | 169 | 17.2 (13.4–20.9) | 137 | 14.9 (11.2–18.7) | 145 | 16.1 (11.4–20.7) | 168 | 16.2 (11.9–20.4) | −0.3 (−0.6 to 0.1) | 0.111 |
| Black, non-Hispanic | 3078 | 58.8 (54.4–63.3) | 591 | 58.1 (48.4–67.9) | 609 | 58.3 (48.3–68.3) | 615 | 58.7 (49.7–67.6) | 636 | 59.7 (50.4–69.1) | 627 | 59.3 (48.1–70.5) | 0.7 (0.5–0.8) | <0.001 |
| Hispanic/Latinab | 995 | 19.0 (14.7–23.2) | 195 | 20.6 (10.8–30.4) | 201 | 17.9 (8.1–27.7) | 211 | 19.3 (10.8–27.8) | 206 | 18.8 (10.9–26.8) | 182 | 18.3 (7.3–29.4) | −1.9 (−2.1 to −1.6) | <0.001 |
| Other | 315 | 6.2 (5.2–7.1) | 49 | 5.5 (3.2–7.7) | 66 | 6.7 (4.6–8.8) | 74 | 7.1 (5.2–8.9) | 61 | 5.3 (3.1–7.6) | 65 | 6.2 (3.9–8.5) | 0.1 (−0.4 to 0.7) | 0.593 |
| Age, in years | ||||||||||||||
| 18–29 | 331 | 6.9 (6.1–7.8) | 77 | 7.7 (5.4–10.1) | 72 | 7.3 (5.8–8.8) | 60 | 6.6 (4.9–8.3) | 56 | 6.7 (4.7–8.6) | 66 | 6.4 (4.7–8.1) | −4.7 (−5.1 to −4.2) | <0.001 |
| 30–39 | 758 | 16.3 (15.1–17.6) | 166 | 18.4 (15.9–21.0) | 146 | 16.2 (13.7–18.8) | 170 | 16.7 (13.9–19.5) | 139 | 15.5 (12.8–18.1) | 137 | 15.0 (11.9–18.1) | −4.6 (−4.9 to −4.3) | <0.001 |
| 40–49 | 1315 | 27.2 (25.8–28.6) | 274 | 29.2 (25.8–32.5) | 288 | 29.6 (27.0–32.1) | 254 | 26.9 (24.1–29.7) | 254 | 25.8 (22.3–29.2) | 245 | 24.8 (21.8–27.7) | −4.5 (−4.8 to −4.3) | <0.001 |
| ≥50 | 2735 | 49.5 (48.0–51.0) | 450 | 44.7 (41.2–48.1) | 539 | 46.9 (44.2–49.7) | 553 | 49.8 (46.4–53.2) | 599 | 52.1 (48.9–55.3) | 594 | 53.9 (50.5–57.2) | 4.9 (4.7–5.1) | <0.001 |
| Poverty thresholdc | ||||||||||||||
| Above poverty threshold | 1763 | 38.9 (36.3–41.4) | 312 | 34.3 (29.7–38.9) | 360 | 40.5 (34.0–47.0) | 375 | 41.3 (34.3–48.2) | 359 | 39.0 (34.0–43.9) | 357 | 39.2 (34.7–43.7) | 2.2 (1.9–2.4) | <0.001 |
| At or below poverty threshold | 2901 | 61.1 (58.6–63.7) | 586 | 65.7 (61.1–70.3) | 588 | 59.5 (53.0–66.0) | 581 | 58.7 (51.8–65.7) | 573 | 61.0 (56.1–66.0) | 573 | 60.8 (56.3–65.3) | −1.3 (−1.5 to −1.2) | <0.001 |
| Educational attainment | ||||||||||||||
| <High school | 1476 | 28.5 (27.1–30.0) | 306 | 33.3 (29.7–36.9) | 293 | 27.2 (24.2–30.2) | 292 | 27.7 (24.4–30.9) | 280 | 25.9 (22.5–29.3) | 305 | 28.7 (25.7–31.7) | −3.6 (−3.8 to −3.3) | <0.001 |
| High school diploma or equivalent | 1573 | 30.8 (29.1–32.4) | 279 | 28.2 (24.2–32.2) | 313 | 30.0 (26.9–33.2) | 316 | 31.1 (27.4–34.8) | 338 | 32.6 (29.0–36.1) | 327 | 31.8 (28.1–35.6) | 3.2 (3.0–3.5) | <0.001 |
| >High school | 2073 | 40.7 (39.0–42.4) | 373 | 38.5 (33.9–43.0) | 436 | 42.7 (38.8–46.7) | 426 | 41.2 (38.0–44.4) | 429 | 41.6 (37.7–45.4) | 409 | 39.4 (36.3–42.5) | 0.2 (−0.0 to 0.4) | 0.138 |
| Health insurance coveraged | ||||||||||||||
| Any private | 1176 | 23.7 (22.0–25.4) | 217 | 23.8 (20.7–26.9) | 245 | 25.3 (20.5–30.0) | 234 | 24.0 (19.0–29.0) | 243 | 22.9 (20.1–25.8) | 237 | 22.5 (19.8–25.1) | −2.1 (−2.4 to −1.8) | <0.001 |
| Public only | 3485 | 66.4 (64.2–68.7) | 656 | 65.3 (60.7–70.0) | 712 | 67.1 (61.5–72.8) | 703 | 65.6 (59.2–71.9) | 702 | 65.6 (60.8–70.4) | 712 | 68.5 (65.1–71.8) | 0.7 (0.6–0.9) | <0.001 |
| Ryan White/ADAP only | 357 | 8.0 (6.6–9.5) | 70 | 8.4 (5.7–11.0) | 66 | 6.1 (3.8–8.3) | 78 | 8.6 (5.0–12.2) | 78 | 9.6 (5.1–14.1) | 65 | 7.5 (4.9–10.1) | 2.1 (1.6–2.6) | <0.001 |
| No coverage/uninsured | 52 | 1.9 (1.2–2.5) | 10 | 2.5 (0.1–4.8) | 8 | 1.5 (0.5–2.5) | 11 | 1.8 (0.5–3.1) | 12 | 1.9 (0.6–3.2) | 11 | 1.6 (0.2–3.0) | −7.2 (−8.0 to −6.3) | <0.001 |
| Ryan White-funded facility | ||||||||||||||
| Yes | 3838 | 76.8 (73.1–80.6) | 750 | 82.7 (74.6–90.8) | 791 | 76.2 (68.5–84.0) | 796 | 76.4 (68.8–84.0) | 758 | 74.4 (64.4–84.4) | 743 | 74.7 (66.3–83.2) | −2.3 (−2.4 to −2.1) | <0.001 |
| No | 1047 | 23.2 (19.4–26.9) | 151 | 17.3 (9.2–25.4) | 205 | 23.8 (16.0–31.5) | 216 | 23.6 (16.0–31.2) | 238 | 25.6 (15.6–35.6) | 237 | 25.3 (16.8–33.7) | 7.9 (7.6–8.2) | <0.001 |
| Depression (major, other)e | ||||||||||||||
| Yes | 1186 | 23.7 (22.3–25.2) | 236 | 27.2 (23.3–31.0) | 281 | 26.8 (24.0–29.6) | 261 | 25.5 (21.8–29.2) | 207 | 20.3 (17.8–22.8) | 201 | 19.0 (16.4–21.6) | −9.2 (−9.5 to −9.0) | <0.001 |
| No | 3866 | 76.3 (74.8–77.7) | 712 | 72.8 (69.0–76.7) | 750 | 73.2 (70.4–76.0) | 758 | 74.5 (70.8–78.2) | 820 | 79.7 (77.2–82.2) | 826 | 81.0 (78.4–83.6) | 3.0 (2.9–3.2) | <0.001 |
| Generalized anxiety disorder (severe or moderate)f | ||||||||||||||
| Yes | 1022 | 20.5 (18.9–22.0) | 205 | 23.0 (19.8–26.1) | 237 | 23.4 (20.1–26.8) | 202 | 19.7 (16.4–23.0) | 193 | 18.5 (15.0–22.0) | 185 | 17.8 (14.2–21.3) | −7.2 (−7.5 to −7.0) | <0.001 |
| No | 4045 | 79.5 (78.0–81.1) | 744 | 77.0 (73.9–80.2) | 795 | 76.6 (73.2–79.9) | 822 | 80.3 (77.0–83.6) | 840 | 81.5 (78.0–85.0) | 844 | 82.2 (78.7–85.8) | 1.9 (1.8–2.1) | <0.001 |
| Intimate partner violenceg | ||||||||||||||
| Yes | 240 | 5.0 (4.2–5.8) | 52 | 5.5 (3.7–7.4) | 57 | 5.8 (4.0–7.6) | 46 | 4.8 (3.4–6.3) | 45 | 5.2 (3.0–7.4) | 40 | 3.7 (2.7–4.7) | −8.4 (−8.9 to −7.9) | <0.001 |
| No | 4765 | 95.0 (94.2–95.8) | 894 | 94.5 (92.6–96.3) | 955 | 94.2 (92.4–96.0) | 965 | 95.2 (93.7–96.6) | 974 | 94.8 (92.6–97.0) | 977 | 96.3 (95.3–97.3) | 0.5 (0.3–0.6) | <0.001 |
| Drug useh | ||||||||||||||
| Yes | 977 | 19.4 (17.9–20.9) | 171 | 18.7 (15.0–22.5) | 190 | 17.1 (14.4–19.8) | 187 | 18.8 (15.8–21.7) | 217 | 21.4 (17.3–25.4) | 212 | 20.9 (17.8–24.1) | 4.6 (4.3–4.9) | <0.001 |
| No | 4111 | 80.6 (79.1–82.1) | 787 | 81.3 (77.5–85.0) | 845 | 82.9 (80.2–85.6) | 840 | 81.2 (78.3–84.2) | 823 | 78.6 (74.6–82.7) | 816 | 79.1 (75.9–82.2) | −1.1 (−1.2 to −0.9) | <0.001 |
| Binge drinkingi | ||||||||||||||
| Yes | 513 | 9.9 (8.9–10.9) | 91 | 8.4 (6.2–10.7) | 99 | 8.7 (6.7–10.7) | 94 | 9.7 (7.8–11.7) | 124 | 12.7 (10.0–15.4) | 105 | 9.9 (7.6–12.1) | 7.2 (6.8–7.7) | <0.001 |
| No | 4556 | 90.1 (89.1–91.1) | 862 | 91.6 (89.3–93.8) | 929 | 91.3 (89.3–93.3) | 934 | 90.3 (88.3–92.2) | 906 | 87.3 (84.6–90.0) | 925 | 90.1 (87.9–92.4) | −0.8 (−0.9 to −0.6) | <0.001 |
| Homelessnessj | ||||||||||||||
| Yes | 423 | 8.3 (7.4–9.2) | 74 | 7.9 (5.5–10.4) | 75 | 7.3 (5.4–9.2) | 88 | 7.8 (5.9–9.7) | 95 | 9.6 (7.9–11.3) | 91 | 8.8 (6.5–11.2) | 5.0 (4.6–5.5) | <0.001 |
| No | 4702 | 91.7 (90.8–92.6) | 886 | 92.1 (89.6–94.5) | 968 | 92.7 (90.8–94.6) | 947 | 92.2 (90.3–94.1) | 951 | 90.4 (88.7–92.1) | 950 | 91.2 (88.8–93.5) | −0.4 (−0.6 to −0.3) | <0.001 |
| Incarceration | ||||||||||||||
| Yes | 142 | 3.1 (2.4–3.7) | 37 | 4.4 (2.2—6.6) | 26 | 2.9 (1.7–4.2) | 25 | 2.7 (1.3–4.1) | 38 | 4.0 (2.5–5.4) | 16 | 1.4 (0.6–2.1) | −15.3 (−16.0 to −14.7) | <0.001 |
| No | 4978 | 96.9 (96.3–97.6) | 922 | 95.6 (93.4–97.8) | 1017 | 97.1 (95.8–98.3) | 1010 | 97.3 (95.9–98.7) | 1004 | 96.0 (94.6–97.5) | 1025 | 98.6 (97.9–99.4) | 0.5 (0.4–0.7) | <0.001 |
EAPC, estimated annual percentage change; Cl, confidence interval; ADAP, AIDS Drug Assistance Program.
AII characteristics were ascertained based on the past 12 months, unless otherwise indicated.
Hispanics or Latinos can be of any race. Persons are classified in only one race/ethnicity category.
Poverty guidelines as defined by HHS; the 2018 guidelines were used for persons interviewed in 201 9 and the 201 9 guidelines were used for persons interviewed in 2020. More information regarding HHS poverty guidelines can be found at https://aspe.hhs.gov/frequently-asked-questions-related-poverty-guidelines-and-poverty.externalicon.
Receipt of Ryan White HIV/AIDS Program (RWHAP) assistance was defined as having RWHAP coverage for medical care or antiretroviral medicines in the past 12 months. Persons could select more than one response for health insurance or coverage for care or medications.
As measured by the Patient Health Questionnaire 8 administered during the interviews; Current depression of moderate or severe intensity was defined as a total score of at least 10.
As measured by the Generalized Anxiety Disorder 7 Scale administered during the interviews; Moderate anxiety was defined as scores 10–14 in the past 2 weeks, severe anxiety at least 15.
Having been slapped, punched, shoved, kicked, choked, or otherwise physically hurt by a romantic or sexual partner.
Four alcoholic drinks among women in one sitting in the past 30days.
Any injection or noninjection drug use.
Living on the street, in a shelter, in a single-room-occupancy hotel, or in a car.
Table 2.
HIV engagement in care outcomes of women diagnosed with HIV by year – Medical Monitoring Project, United States 2015–2019a.
| 2015 |
2016 |
2017 |
2018 |
2019 |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall | N 967 | Col % (95% CI) | n 1045 | Col % (95% CI) | n 1037 | Col % (95% CI) | n 1048 | Col % (95% CI) | n 1042 | Col % (95% CI) | EAPC | P value |
| Ever HIV disease stage 3b | ||||||||||||
| Yes | 575 | 55.8 (51.0–60.5) | 634 | 56.5 (53.1–59.9) | 590 | 54.2 (51.1–57.2) | 610 | 54.6 (49.6–59.6) | 665 | 61.5 (58.1–64.8) | 1.7 (1.5–1.9) | <0.001 |
| No | 392 | 44.2 (39.5–49.0) | 407 | 43.5 (40.1–46.9) | 446 | 45.8 (42.8–48.9) | 438 | 45.4 (40.4–50.4) | 377 | 38.5 (35.2–41.9) | ||
| Current advanced diseasec | ||||||||||||
| Yes | 146 | 14.1 (11.0–17.2) | 160 | 14.7 (12.6–16.8) | 158 | 13.9 (11.7–16.1) | 149 | 13.6 (11.8–15.3) | 151 | 15.2 (13.3–17.2) | 0.8 (0.4–1.1) | <0.001 |
| No | 790 | 85.9 (82.8–89.0) | 867 | 85.3 (83.2–87.4) | 854 | 86.1 (83.9–88.3) | 847 | 86.4 (84.7–88.2) | 829 | 84.8 (82.8–86.7) | ||
| Retention in cared | ||||||||||||
| Yes | 815 | 77.8 (73.4–82.2) | 883 | 80.7 (76.9–84.5) | 865 | 79.7 (76.1–83.4) | 834 | 76.8 (73.2–80.5) | 824 | 79.8 (75.8–83.7) | 0.0 (−0.1 to 0.2) | 0.907 |
| No | 129 | 22.2 (17.8–26.6) | 146 | 19.3 (15.5–23.1) | 152 | 20.3 (16.6–23.9) | 167 | 23.2 (19.5–26.8) | 162 | 20.2 (16.3–24.2) | ||
| ART prescriptione | ||||||||||||
| Yes | 835 | 81.5 (78.1–84.8) | 928 | 84.8 (81.1–88.6) | 919 | 85.2 (81.8–88.6) | 902 | 80.7 (78.1–83.4) | 903 | 83.2 (80.3–86.1) | −0.1 (−0.2 to 0.1) | 0.229 |
| No | 132 | 18.5 (15.2–21.9) | 117 | 15.2 (11.4–18.9) | 118 | 14.8 (11.4–18.2) | 146 | 19.3 (16.6–21.9) | 139 | 16.8 (13.9–19.7) | ||
| Perfect ART adherence (score of 100 on the adherence scale) during the past 30 daysf | ||||||||||||
| Yes | 516 | 59.4 (54.7–64.1) | 573 | 58.8 (56.1–61.6) | 583 | 58.6 (54.8–62.5) | 576 | 58.0 (54.3–61.6) | 615 | 61.9 (57.8–66.0) | 0.8 (0.6–0.9) | <0.001 |
| No | 352 | 40.6 (35.9–45.3) | 402 | 41.2 (38.4–43.9) | 385 | 41.4 (37.5–45.2) | 400 | 42.0 (38.4–45.7) | 377 | 38.1 (34.0–42.2) | ||
| One or more missed appointments | ||||||||||||
| Yes | 256 | 26.9 (24.0–29.8) | 278 | 26.0 (23.6–28.4) | 290 | 27.8 (24.9–30.6) | 284 | 28.8 (24.9–32.7) | 265 | 25.9 (22.6–29.2) | 0.3 (0.1–0.6) | 0.01 |
| No | 698 | 73.1 (70.2–76.0) | 755 | 74.0 (71.6–76.4) | 738 | 72.2 (69.4–75.1) | 746 | 71.2 (67.3–75.1) | 764 | 74.1 (70.8–77.4) | ||
| Viral suppression at last testg | ||||||||||||
| Yes | 688 | 67.0 (63.9–70.1) | 775 | 69.4 (64.1–74.7) | 768 | 69.4 (64.7–74.1) | 750 | 65.9 (62.4–69.5) | 740 | 66.0 (62.5–69.4) | −0.8 (−1.0 to −0.7) | <0.001 |
| No | 279 | 33.0 (29.9–36.1) | 270 | 30.6 (25.3–35.9) | 269 | 30.6 (25.9–35.3) | 298 | 34.1 (30.5–37.6) | 302 | 34.0 (30.6–37.5) | ||
| Sustained viral suppressionh | ||||||||||||
| Yes | 610 | 60.1 (56.4–63.8) | 682 | 61.3 (56.4–66.2) | 666 | 60.9 (56.6–65.2) | 672 | 59.7 (55.8–63.5) | 661 | 59.2 (55.8–62.5) | −0.6 (−0.8 to −0.4) | <0.001 |
| No | 357 | 39.9 (36.2–43.6) | 363 | 38.7 (33.8–43.6) | 371 | 39.1 (34.8–43.4) | 376 | 40.3 (36.5–44.2) | 381 | 40.8 (37.5–44.2) | ||
ART, antiretroviral therapy; CI, confidence interval.
All outcomes are measured over the past 12 months, except where otherwise noted.
Ever had been classified as stage 3 HIV based on the revised CDC stage of disease classifications for HIV infection.
Advanced HIV disease was defined by CD4+ less than 200 cells/ml or diagnosis of an opportunistic infection in the past 12 months.
Retention in care was defined as two HIV care elements at least 90 days apart including documentation in the medical record of the following: encounter with an HIV care provider (could also be self-reported), viral load test result, CD4+ test result, HIV resistance test or tropism assay, ART prescription, PCP prophylaxis, or MAC prophylaxis.
Any ART prescription in the medical record over the past 12 months.
Persons currently taking ART were asked about their adherence to ART in the 30 days before the interview using questions from a three-item scale that ranges from 0 to 100, with a score of 100 indicating perfect adherence. A person was 100% adherent if they had a score of 100.
Most recent viral load that was undetectable or less than 200 copies/ml.
All viral loads in the past 12 months undetectable or less than 200 copies/ml.
Statistical analyses
The analysis was limited to adults with diagnosed HIV infection who identified as cisgender women during the 2015–2019 data collection cycles (N = 5139). Weighted percentages with 95% confidence intervals (CIs) were reported for all characteristics. The estimated annual percentage change (EAPC) and the associated 95% CI was used to assess trends from 2015 to 2019 among WWH. EAPCs indicate the relative annual change in the weighted percentages of HIV outcomes. EAPCs were considered meaningful from a public health perspective if at least 1% with P values less than 0.05. All analyses were conducted using SAS and SAS-callable SUDAAN.
Results
Demographic characteristics, social determinants of health, and behavioral characteristics
During 2015–2019, overall, 58.8% of cisgender women with diagnosed HIV infection were Black (95% CI 54.4–63.3), 19% were Hispanic/Latina (95% CI 14.7–23.2), and 16% were White (95% CI 14.1–17.9) persons (Table 1). Trend analysis for sociodemographic characteristics varied. At the time of the MMP interview, 49.5% (95% CI 48.0–51.0) were at least 50 years of age, 69.6% (95% CI 67.9–71.4) had been living with HIV for at least 10 years, 28.5% (95% CI 27.1–30.0) had less than high school level education, 30.8% (95% CI 29.1–32.4) had a high school diploma or equivalent educational attainment, 61.1% (95% CI 58.6–63.7) were in a household living at or below poverty level, and 8.3% (95% CI 7.4–9.2) were homeless at any time in the past 12 months. Additionally, 66.4% (95% CI 64.2–68.7) had public insurance only, 23.7% (95% CI 22.0–25.4) had any private insurance, 8.0% (95% CI 6.6–9.5) had RWHAP only, and 1.9% (95% CI 1.2–2.5) were uninsured. Overall, 23.7% (95% CI 22.3–25.2) had symptoms of depression, 20.5% (95% CI 18.9–22.0) had symptoms of generalized anxiety disorder, 19.4% (95% CI 17.9–20.9) used injection or noninjection drugs, and 9.9% (95% CI 8.9–10.9) reported binge drinking.
Trends in HIV outcomes
According to the Centers for Disease Control and Prevention (CDC) stage of disease classification for HIV infection, an estimated 55.8% (95% CI 51.0–60.5) of women ever had stage 3 disease (AIDS) in 2015 and 61.5% (95% CI 58.1–64.8) in 2019 [9]. Additionally, 14.1% (95% CI 11–17.2) of women with diagnosed HIV infection had advanced disease in 2015 and 15.2% (95% CI 13.3–17.2) in 2019. Of all WWH, 77.8% (95% CI 73.4–82.2) were retained in care in 2015 and 79.8% (95% CI 75.8–83.7) in 2019. In total, 81.5% (95% CI 78.1–84.8) had a current ART prescription in 2015 as did 83.2% (95% CI 80.3–86.1) in 2019. Among those currently taking ART, 59.4% (95% CI 54.7–64.1) reported perfect dose adherence in 2015 as did 61.9% (95% CI 57.8–66) in 2019. Overall, 26.9% (95% CI 24–29.8) reported missed appointments in 2015 as did 25.9% (95% CI 22.6–29.2) in 2019. Further, 67.0% (95% CI 63.9–70.1) were virally suppressed at their last viral load in 2015 as were 66.0% (95% CI 62.5–69.4) in 2019. An estimated 60.1% (95% CI 56.4–63.8) had sustained viral suppression in 2015 as did 59.2% (95% CI 55.8–62.5) in 2019 (Table 2).
Trend analyses of data between 2015 and 2019 indicated that the prevalence of persons whose HIV infection had ever been classified as stage 3 meaningfully increased (EAPC 1.7%; CI 1.5–1.9; P < 0.001). Other trend analyses between 2015 and 2019 indicated that the prevalence of current advanced disease (EAPC: 0.8%; CI 0.4–1.1; P < 0.001), retention in care (EAPC: 0.0%; CI −0.1 to 0.2; P = 0.91), current ART prescription (EAPC: −0.1; CI −0.2 to 0.1; P = 0.23), perfect adherence to ART (EAPC: 0.8%; 95% CI 0.6–0.9; P < 0.001), missed appointments (EAPC: 0.3%; CI 0.1–0.6; P = 0.01), viral suppression based on last test (EAPC −0.8%; CI —1.0 to −0.7; P < 0.001), and sustained viral suppression (EAPC: −0.6%; CI −0.8 to −0.4; P < 0.001) did not meaningfully change over time among women with diagnosed HIV infection (Table 2).
Discussion
During 2015 to 2019, HIV care continuum outcomes did not meaningfully improve among WWH. Further, the prevalence of persons whose HIV infection had ever been classified as stage 3 meaningfully increased, possibly reflecting poorly controlled HIV among WWH. The HIV care continuum estimates among WWH continue to be suboptimal, including viral suppression, which falls short of the national goal of 95% of people with diagnosed HIV infection being virally suppressed. These suboptimal outcomes may slow progress towards ending the HIV epidemic.
Women represent nearly a quarter of the people with HIV in the United States [1]. Structural factors, such as stigma, racism, and misogyny –which influence access to educational and economic opportunities, while reducing community standing and social capital – harm outcomes in WWH [10,11]. In contrast to our findings for viral suppression among WWH (EAPC: −0.8%), analyses from other national datasets from 2014 to 2018 indicate greater improvements among all adults and MSM (EAPCs >6%), suggesting WWH may be disproportionately affected by HIV [12,13]. Our study suggests that WWH were more likely to live at or below the federal poverty threshold and have less than high school educational attainment compared with people in the pooled gender analyses [14]. To reach national HIV goals, more research is needed to understand and address barriers to HIV care and medication adherence among women, including structural forces and social determinants of health that may contribute to the lack of improvement in the HIV care continuum trends, such as unemployment, lack of childcare, and transportation support, which might result from family caretaking [15].
The Health Resources and Services Administration (HRSA), HIV/AIDS Bureau, is investing in multimodal integrated strategies to improve HIV outcomes among women, such as bundled interventions that produce better health outcomes when implemented together versus separately [16]. These packages may include enhanced patient navigation and case management, which provides support and addresses barriers to accessing HIV care, in addition to interventions that address stigma reduction, IPV, health literacy and resiliency, behavioral health needs, and the use of trauma-informed care [16]. Other interventions to improve HIV outcomes among WWH include adopting a shared decision-making model using clear, respectful, positive communication without stigma while sharing information that considers patient health literacy level [10,17–20]. Training providers on techniques for promoting trust in patient–provider relationships, addressing structural discrimination and racism in clinical settings, and implementing CDC-recommended high-impact HIV prevention and treatment methods for women may help to increase ART adherence and viral suppression [20,21].
Our analysis has several limitations. The findings are partially based on self-reported information, including medication adherence, and therefore are subject to recall and desirability biases. Suboptimal response rates were observed in the years surveyed. However, the study estimates are adjusted for nonresponse. Despite suboptimal response rates, results obtained from the sampling strategy can still yield useful results and provide much needed population-based data on WWH [9].
In conclusion, HIV care continuum outcomes among WWH did not meaningfully improve from 2015–2019, suggesting more attention is needed to achieve the National HIV/AIDS Strategy goal of Ending the HIV Epidemic in the United States. To improve the health of WWH and reduce onward transmission of HIV, multifaceted interventions to retain women in care, increase ART adherence, and enhanced efforts to address social determinants of health that influence HIV clinical outcomes in this important population are needed.
Acknowledgements
We thank MMP participants, project area staff, and Provider and Community Advisory Board members.
Funding for the Medical Monitoring Project is provided by the Centers for Disease Control and Prevention.
Disclaimer:
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Footnotes
Conflicts of interest
There are no conflicts of interest.
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