Abstract
Using data from the National HIV Surveillance System, we examined HIV infections diagnosed between 2010 and 2015 attributed to heterosexual contact with partners previously known to be HIV infected. More than 4 in 10 HIV infections among heterosexual males and 5 in 10 HIV infections among heterosexual females were attributed to this group. Findings may inform the prioritization of prevention and care efforts and resource allocation modeling for reducing new HIV infection among discordant partnerships.
Effective strategies are available for preventing HIV transmission through heterosexual contact. Condom use has been a key method used by discordant couples to reduce transmission risk.1 Biomedical interventions such as antiretroviral therapy (ART) for treatment of HIV infection and antiretroviral drugs taken for preexposure prophylaxis (PrEP) by uninfected partners have also been shown to reduce HIV transmission risk among heterosexual discordant couples.2–5 The World Health Organization, U.S. Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration, and National Institutes of Health recommend that clinical and non-clinical providers offer information on all prevention methods that HIV-discordant couples can use to reduce the risk of HIV transmission during routine care and service visits.6,7
Despite the availability of effective biomedical and behavioral prevention strategies, around 10,000 persons with HIV diagnosed each year in the United States have infections attributed to heterosexual contact.8 Many of these infections may be the result of heterosexual contact with partners who were previously known to be HIV infected. Examining the number of persons who acquired HIV infection through heterosexual contact with known HIV-infected partners can inform effective prevention planning and resource allocation to reduce HIV transmission among serodiscordant heterosexual partnerships.
Using data from the National HIV Surveillance System (NHSS), we determined the number of males and females aged ≥13 years with HIV diagnosed between 2010 and 2015 who had their infection attributed to heterosexual contact. Data were reported to CDC through December 2016 from 50 U.S. states and Washington, D.C. Classification of HIV transmission risk was based on patient history recorded by health care providers or health department disease investigation specialists.8 We included persons who had sex with an opposite sex partner and excluded men who have ever had sexual contact with both men and women and persons who had injected drugs. Persons whose risk factors were not reported were also excluded from the analysis. We further categorized heterosexual contact into one of the four groups: (1) heterosexual contact with injection drug use partners, (2) heterosexual contact with bisexual male (only applied to female), (3) heterosexual contact with partners with unspecified risk, and (4) heterosexual contact with known HIV-infected partners.
Between 2010 and 2015, 43% to 45% of heterosexual males with HIV indicated that they had sex with female partners who were previously known to be HIV infected; 3% to 4% indicated sex with female injection drug use partners; and 52% to 54% indicted sex with female partners with unspecified risk. Among heterosexual females with HIV, 53% to 55% indicated that they had sex with male partners who were previously known to be HIV infected; 3% to 5% indicated sex with male injection drug use partners; about 3% indicated sex with bisexual male, and 37% to 40% indicated sex with male partners with unspecified risk (Table 1). Further examination of individual characteristics showed that blacks/African Americans, 35–44 and 45–54 age groups, and persons residing in the South had higher percentages of persons who reported sexual contact with partners known to be HIV infected. The pattern was the same for males and females.
Table 1.
Number of HIV infections attributed to heterosexual contact, by sex and year of diagnosis and selected characteristics, 2010–2015, United States
| Characteristics | Male | Female | ||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
| ||||||||||||||||||||||||
| 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | |||||||||||||
|
| ||||||||||||||||||||||||
| N | % | N | % | N | % | N | % | N | % | N | % | N | % | N | % | N | % | N | % | N | % | N | % | |
| Reported having sex with an opposite sex partner | 6273 | 100% | 5747 | 100% | 5532 | 100% | 5293 | 100% | 5116 | 100% | 5009 | 100% | 7650 | 100% | 7155 | 100% | 6737 | 100% | 6333 | 100% | 6342 | 100% | 6019 | 100% |
| Heterosexual contact with injection drug users | 228 | 3.6% | 185 | 3.2% | 167 | 3.0% | 171 | 3.2% | 156 | 3.0% | 134 | 2.7% | 397 | 5.2% | 320 | 4.5% | 253 | 3.8% | 213 | 3.4% | 221 | 3.5% | 206 | 3.4% |
| Heterosexual contact with bisexual men | – | – | – | – | – | – | – | – | – | – | – | – | 237 | 3.1% | 223 | 3.1% | 181 | 2.7% | 190 | 3.0% | 193 | 3.0% | 168 | 2.8% |
| Heterosexual contact with partners with unspecified risk | 3292 | 52.5% | 2968 | 51.6% | 2973 | 53.7% | 2828 | 53.4% | 2692 | 52.6% | 2618 | 52.3% | 2835 | 37.1% | 2778 | 38.8% | 2714 | 40.3% | 2432 | 38.4% | 2556 | 40.3% | 2428 | 40.3% |
| Heterosexual contact with known HIV-infected partners | 2753 | 43.9% | 2594 | 45.1% | 2392 | 43.2% | 2294 | 43.3% | 2268 | 44.3% | 2257 | 45.1% | 4181 | 54.7% | 3834 | 53.6% | 3589 | 53.3% | 3498 | 55.2% | 3372 | 53.2% | 3217 | 53.4% |
|
|
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| Among persons infected with HIV through heterosexual contact with known HIV-positive partners | ||||||||||||||||||||||||
| Race/Ethnicity | ||||||||||||||||||||||||
| Black/African American | 1754 | 63.7% | 1660 | 64.0% | 1530 | 64.0% | 1374 | 59.9% | 1395 | 61.5% | 1430 | 63.4% | 2764 | 66.1% | 2546 | 66.4% | 2378 | 66.3% | 2330 | 66.6% | 2198 | 65.2% | 2124 | 0.7 |
| Hispanic/Latino | 518 | 18.8% | 505 | 19.5% | 440 | 18.4% | 464 | 20.2% | 463 | 20.4% | 430 | 19.1% | 674 | 16.1% | 598 | 15.6% | 537 | 15.0% | 528 | 15.1% | 520 | 15.4% | 478 | 0.1 |
| White | 339 | 12.3% | 325 | 12.5% | 314 | 13.1% | 330 | 14.4% | 301 | 13.3% | 292 | 12.9% | 511 | 12.2% | 497 | 13.0% | 476 | 13.3% | 475 | 13.6% | 485 | 14.4% | 465 | 0.1 |
| Other | 142 | 5.2% | 104 | 4.0% | 108 | 4.5% | 126 | 5.5% | 109 | 4.8% | 105 | 4.7% | 232 | 5.5% | 193 | 5.0% | 198 | 5.5% | 165 | 4.7% | 169 | 5.0% | 150 | 0.0 |
| Age at diagnosis | ||||||||||||||||||||||||
| 13–24 | 237 | 8.6% | 211 | 8.1% | 231 | 9.7% | 203 | 8.8% | 201 | 8.9% | 211 | 9.3% | 724 | 17.3% | 664 | 17.3% | 551 | 15.4% | 541 | 15.5% | 521 | 15.5% | 466 | 0.1 |
| 25–34 | 600 | 21.8% | 567 | 21.9% | 530 | 22.2% | 557 | 24.3% | 537 | 23.7% | 541 | 24.0% | 1139 | 27.2% | 1015 | 26.5% | 971 | 27.1% | 924 | 26.4% | 906 | 26.9% | 858 | 0.3 |
| 35–44 | 789 | 28.7% | 720 | 27.8% | 619 | 25.9% | 592 | 25.8% | 596 | 26.3% | 572 | 25.3% | 1075 | 25.7% | 926 | 24.2% | 873 | 24.3% | 802 | 22.9% | 862 | 25.6% | 765 | 0.2 |
| 45–54 | 723 | 26.3% | 694 | 26.8% | 635 | 26.5% | 566 | 24.7% | 578 | 25.5% | 512 | 22.7% | 805 | 19.3% | 797 | 20.8% | 772 | 21.5% | 776 | 22.2% | 648 | 19.2% | 660 | 0.2 |
| 55+ | 404 | 14.7% | 402 | 15.5% | 377 | 15.8% | 376 | 16.4% | 356 | 15.7% | 421 | 18.7% | 438 | 10.5% | 432 | 11.3% | 422 | 11.8% | 455 | 13.0% | 435 | 12.9% | 468 | 0.1 |
| Region of residence | ||||||||||||||||||||||||
| Northeast | 662 | 24.0% | 604 | 23.3% | 565 | 23.6% | 510 | 22.2% | 535 | 23.6% | 421 | 18.7% | 837 | 20.0% | 776 | 20.2% | 665 | 18.5% | 591 | 16.9% | 574 | 17.0% | 532 | 0.2 |
| Midwest | 266 | 9.7% | 231 | 8.9% | 221 | 9.2% | 237 | 10.3% | 188 | 8.3% | 194 | 8.6% | 398 | 9.5% | 385 | 10.0% | 394 | 11.0% | 381 | 10.9% | 339 | 10.1% | 324 | 0.1 |
| South | 1596 | 58.0% | 1581 | 60.9% | 1432 | 59.9% | 1344 | 58.6% | 1351 | 59.6% | 1448 | 64.2% | 2560 | 61.2% | 2353 | 61.4% | 2179 | 60.7% | 2217 | 63.4% | 2152 | 63.8% | 2097 | 0.7 |
| West | 229 | 8.3% | 178 | 6.9% | 174 | 7.3% | 203 | 8.8% | 194 | 8.6% | 194 | 8.6% | 386 | 9.2% | 320 | 8.3% | 351 | 9.8% | 309 | 8.8% | 307 | 9.1% | 264 | 0.1 |
| Total | 2753 | 100% | 2594 | 100% | 2392 | 100% | 2294 | 100% | 2268 | 100% | 2257 | 100% | 4181 | 100% | 3834 | 100% | 3589 | 100% | 3498 | 100% | 3372 | 100% | 3217 | 100% |
Our analyses suggest that heterosexual contact with partners known to be HIV infected accounted for more than 4 in 10 HIV infections among heterosexual males and more than 5 in 10 HIV infections among heterosexual females between 2010 and 2015. Many of these infections could have been averted if discordant couples were aware of and were offered effective biomedical and behavioral prevention methods that they could use to reduce the risk of HIV transmission.9 A previous study estimated 624,000 heterosexually active adults aged 18–59 years old had substantial risks for acquiring HIV consistent with PrEP indications.10 Our finding shows, on average, 6,000 males and females per year whose HIV infections were attributed to heterosexual contact with partners known to be HIV infected – pointing out the importance of prioritizing uninfected partners in discordant relationships for PrEP. While viral suppression among persons living with HIV is also an effective mean in reducing HIV transmission,11 approximately 50.1% heterosexual males and 53.4% heterosexual females with diagnosed HIV had viral suppression in 2013, far short of the national goal of 80%.12 Additionally, an estimated 15.6% of persons living with HIV infection attributed to heterosexual contact are not aware of their infection.13 These figures corroborate the call from various guidelines for HIV treatment and PrEP use among discordant partnerships.6–7 Health care and service providers could play an important role in getting HIV-infected persons into HIV treatment, raising awareness and increasing delivery of PrEP and other highly effective HIV prevention services to HIV-infected patients and their uninfected partners.10 As more and more providers adopt the guidelines,6–7 we hope to see a reduction in the number of HIV infections attributed to heterosexual contact with partners who were previously known to be HIV infected. Considering the lifetime HIV treatment costs ranging from $253,000 to $402,000 per person,14 averting HIV infections in discordant partnerships with effective biomedical and behavioral prevention methods is likely to be a cost-saving strategy.
One limitation of our study is that transmission risk is determined based on patient history. The confirmation of partners with documented HIV infection is not required and the time relationship between the sex partner’s HIV infection diagnosis and the point in time that the sex partner engaged in the risk behavior cannot be ascertained. Additionally, we excluded men who have ever had sexual contact with both men and women, persons who injected drugs, and persons whose risk factors were not reported or identified.
Despite these limitations, our analyses provide additional insight into heterosexual transmission of HIV in the United States. The number of persons whose infections were attributed to heterosexual contact with partners known to be HIV infected reveals the number of HIV infections that would have potentially been prevented if the combination of effective biomedical and behavior methods were strategically used in discordant partnerships. It is hoped that our data will inform the prioritization of prevention and care efforts and resource allocation modeling for reducing new HIV infection.
Acknowledgments
Funding. This work was supported by the Division of HIV/AIDS Prevention at the U.S. Centers for Disease Control and Prevention and was not funded by any other organization.
Footnotes
Disclaimer. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention.
Conflict of Interest. Crepaz, Dong, Chen, and Hall reported no conflicts.
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