Abstract
There has been increasing emphasis on care and treatment for persons with human immunodeficiency virus (HIV) in the United States during the past decade,1,2 including the use of antiretroviral therapy for increasing survival and decreasing transmission.1 Accurate HIV diagnosis data recently became available for all states,3 allowing for the first time an examination of long-term national trends. These data can be used to monitor awareness of serostatus among persons living with HIV, primary prevention efforts, and testing initiatives. We examined trends in HIV diagnoses from 2002–2011 in the United States using data from the National HIV Surveillance System of the US Centers for Disease Control and Prevention (CDC).
Methods |
To assess trends in HIV diagnoses, we analyzed cases of HIV infection diagnosed during 2002–2011 among persons aged 13 years or older reported through December 2012. All data were collected through routine HIV surveillance mandated by laws or regulations in the 50 states and the District of Columbia. Ethical review for this data collection is waived.
Data on race/ethnicity were identified by health department personnel conducting active surveillance and reviewing medical records. Multiple imputation was used to assign transmission category to cases reported without an identified risk factor (124 447; 25.2%).3 Population denominators for calculating rates were obtained from the US Census Bureau.
We estimated annual percentage change (EAPC) in HIV diagnosis rates by using Poisson regression with no covariates4; logarithms of rate denominators served as offsets. Case counts (rather than rates) were used to analyze diagnoses by transmission category due to lack of population denominators. The significance of a trend was determined by whether the 95% confidence interval for the EAPC included 0. Data were analyzed using SAS version 9.3 (SAS Institute Inc).
Results |
During2002–2011,493 372personswerediagnosedwith HIV in the United States. The annual diagnosis rate decreased by 33.2% (EAPC = −4.0%; 95% CI, −4.1 to −3.9) from 24.1 per 100 000 population in 2002 to 16.1 in 2011 (Table 1). Statistically significant decreases in the EAPC of diagnosis rates were found in nearly every demographic population with the largest changes observed in women, persons aged 35–44 years, and persons of multiple races. Changes were not evident for Asians or Native Hawaiians/other Pacific Islanders.
Table 1.
Human Immunodeficiency Virus (HIV) Diagnoses Among Persons Aged 13 Years or Older in the United States
| HIV Diagnosis Rate/100 000 Population by Year of Diagnosis | % Change | EAPC (95% CI) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | 2011 | |||
| Sex | ||||||||||||
| Male | 35.8 | 33.5 | 33.2 | 31.4 | 31.2 | 31.5 | 30.3 | 28.4 | 26.9 | 26.1 | −27.1 | −3.1 (−3.2 to −3.0) |
| Female | 13.0 | 11.7 | 11.2 | 10.3 | 10.1 | 9.9 | 9.2 | 8.1 | 7.2 | 6.6 | −49.2 | −6.6 (−6.8 to −6.4) |
| Age group, y | ||||||||||||
| 13–24 | 12.5 | 12.4 | 13.2 | 13.6 | 14.8 | 16.1 | 17.3 | 17.5 | 17.6 | 17.3 | 38.4 | 4.6 (4.4 to 4.9) |
| 25–34 | 39.8 | 36.0 | 35.5 | 33.5 | 32.6 | 32.9 | 31.8 | 29.5 | 28.5 | 27.8 | −30.2 | −3.6 (−3.7 to −3.4) |
| 35–44 | 46.2 | 42.7 | 41.2 | 37.6 | 36.6 | 34.8 | 31.3 | 28.0 | 25.0 | 22.9 | −50.4 | −7.1 (−7.3 to −7.0) |
| 45–54 | 25.9 | 24.7 | 23.9 | 23.0 | 22.9 | 23.2 | 22.0 | 19.8 | 18.3 | 17.8 | −31.3 | −3.8 (−4.0 to −3.6) |
| ≥55 | 6.2 | 5.9 | 6.2 | 5.8 | 5.7 | 6.0 | 5.9 | 5.3 | 5.0 | 4.8 | −22.6 | −2.5 (−2.8 to −2.1) |
| Race/ethnicitya | ||||||||||||
| American Indian/Alaska Native | 12.9 | 12.5 | 11.7 | 11.7 | 10.5 | 10.7 | 11.3 | 10.2 | 11.3 | 10.0 | −22.5 | −2.3 (−3.8 to −0.8) |
| Asian | 6.2 | 6.3 | 6.5 | 6.0 | 6.3 | 7.2 | 7.0 | 6.4 | 5.8 | 6.4 | 3.2 | 0.1 (−0.7 to 1.0) |
| Black | 99.4 | 90.9 | 89.1 | 81.7 | 80.3 | 80.1 | 79.0 | 71.6 | 66.7 | 62.6 | −37.0 | −4.4 (−4.6 to −4.3) |
| Hispanicb | 37.5 | 34.3 | 31.9 | 30.0 | 30.3 | 29.7 | 27.3 | 25.5 | 22.6 | 22.0 | −41.3 | −5.4 (−5.6 to −5.2) |
| Native Hawaiian/other Pacific Islander | 16.1 | 26.7 | 20.4 | 20.8 | 26.3 | 21.3 | 22.0 | 21.8 | 14.3 | 16.7 | 3.7 | −2.6 (−5.0 to −0.1) |
| White | 10.1 | 9.5 | 9.4 | 9.0 | 8.8 | 8.8 | 8.1 | 7.5 | 7.2 | 6.9 | −31.7 | −4.0 (−4.1 to −3.8) |
| Multiple races | 52.5 | 43.1 | 45.8 | 47.5 | 39.4 | 42.1 | 38.1 | 33.2 | 25.7 | 22.5 | −57.1 | −7.7 (−8.3 to −7.1) |
| Total | 24.1 | 22.3 | 21.9 | 20.6 | 20.4 | 20.4 | 19.6 | 18.0 | 16.8 | 16.1 | −33.2 | −4.0 (−4.1 to −3.9) |
| No. of HIV Diagnoses by Transmission Category and Year of Diagnosisc | ||||||||||||
| Males | ||||||||||||
| MTM sexual contact | 26 021 | 25 251 | 26 240 | 25 838 | 26 313 | 27 614 | 27 466 | 26 685 | 26 035 | 26 033 | 0 | 0.3 (0.1 to 0.5) |
| Injection drug use | 6004 | 5199 | 4592 | 4064 | 3860 | 3424 | 2937 | 2436 | 2102 | 1795 | −70.1 | −11.8 (−12.5 to −11.1) |
| Both of the above | 2850 | 2587 | 2473 | 2320 | 2085 | 1956 | 1732 | 1513 | 1397 | 1211 | −57.5 | −8.6 (−9.4 to −7.8) |
| Heterosexual contactd | 5980 | 5628 | 5546 | 5040 | 5187 | 5266 | 5043 | 4508 | 4123 | 3910 | −34.6 | −4.0 (−4.6 to −3.5) |
| Othere | 155 | 118 | 107 | 83 | 79 | 52 | 60 | 39 | 37 | 31 | −80.0 | −16.3 (−23.0 to −9.0) |
| Subtotal | 41 010 | 38 783 | 38 958 | 37 345 | 37 524 | 38 313 | 37 238 | 35 181 | 33 694 | 32 980 | −27.1 | −3.1 (−3.2 to −3.0) |
| Females | ||||||||||||
| Injection drug use | 3892 | 3324 | 3060 | 2666 | 2443 | 2215 | 1981 | 1658 | 1358 | 1218 | −68.7 | −11.5 (−12.4 to −10.6) |
| Heterosexual contactd | 11 695 | 10 896 | 10 651 | 10 094 | 10 169 | 10 262 | 9836 | 8755 | 8094 | 7507 | −35.8 | −4.1 (−4.4 to −3.8) |
| Othere | 119 | 103 | 89 | 73 | 58 | 42 | 32 | 22 | 17 | 15 | −87.4 | −20.4 (−28.4 to −11.6) |
| Subtotal | 15 705 | 14 323 | 13 800 | 12 834 | 12 670 | 12 519 | 11 850 | 10 435 | 9470 | 8740 | −49.2 | −6.6 (−6.8 to −6.4) |
| Total | 56 715 | 53 106 | 52 758 | 50 179 | 50 194 | 50 832 | 49 088 | 45 616 | 43 164 | 41 720 | −33.2 | −4.0 (−4.1 to 3.9) |
Abbreviations: EAPC, estimated annual percentage change; MTM, male-to-male.
Definitions based on standards for the classification of federal data from the US Office of Management and Budget.
Can be of any race.
Rates not provided due to lack of denominator data for risk populations from the US Census Bureau.
Indicates contact with a person known to have, or to be at high risk for, HIVinfection.
Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
From 2002–2011, the annual number of HIV diagnoses decreased in persons with infection attributed to injection drug use or to heterosexual contact (Table 1). Diagnoses attributed to male-to-male sexual contact remained stable overall, increasing among males aged 13–24, 45–54, and 55 years or older, and decreasing among males aged 35–44 years (Table 2). The largest change (132.5%; EAPC = 10.5) was observed among males aged 13–24 years.
Table 2.
Human Immunodeficiency Virus (HIV) Diagnoses Among Males With Infection Attributed to Male-to-Male Sexual Contact
| No. of HIV Diagnoses Among Males With Infection Attributed to Male-to-Male Sexual Contact by Year of Diagnosisa | % Change | EAPC (95% CI) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | 2011 | |||
| Age group, y | ||||||||||||
| 13–24 | 2976 | 3207 | 3748 | 4107 | 4690 | 5449 | 6208 | 6528 | 6912 | 6919 | 132.5 | 10.5 (10.1 to 10.9) |
| 25–34 | 7957 | 7474 | 7657 | 7506 | 7379 | 7867 | 7868 | 7854 | 7738 | 7929 | −0.4 | 0.3 (0 to 0.6) |
| 35–44 | 9782 | 9296 | 9284 | 8642 | 8563 | 8125 | 7264 | 6537 | 5824 | 5417 | −44.6 | −6.2 (−6.5 to −5.8) |
| 45–54 | 3936 | 3933 | 4090 | 4145 | 4217 | 4564 | 4471 | 4185 | 4040 | 4145 | 5.3 | 0.6 (0.1 to 1.1) |
| ≥55 | 1370 | 1342 | 1462 | 1439 | 1465 | 1609 | 1655 | 1581 | 1521 | 1623 | 18.5 | 2.0 (1.0 to 3.0) |
| Total | 26 021 | 25 251 | 26 240 | 25 838 | 26 313 | 27 614 | 27 466 | 26 685 | 26 035 | 26 033 | 0 | 0.3 (0.1 to 0.5) |
Abbreviation: EAPC, estimated annual percentage change.
The number of HIV diagnoses resulted from statistical adjustment that accounted for missing transmission category.
Discussion |
Nationally, the annual HIV diagnosis rate decreased more than 30% in the past decade. Declines were observed in several key populations; however, increases were found among certain age groups of men who have sex with men, especially young men. Because of delays in diagnosis, temporal trends in diagnoses and variations among groups may reflect earlier changes in HIV incidence.
This study is limited in that trends in diagnoses can be influenced by changes in testing patterns. The HIV testing services were expanded during the analysis period and early outcomes of testing initiatives often indicate increases in diagnoses until some level of testing saturation occurs. Our study found overall decreases in annual diagnosis rates despite the implementation of testing initiatives during the period of analysis. Although increases in diagnoses were found in young men who have sex with men, reports show that many at high risk do not test annually and the overall percentage of youth who had ever tested for HIV during the period of analysis was low compared with other age groups.5,6
Among men who have sex with men, unprotected risk behaviors in the presence of high prevalence and unsuppressed viral load may continue to drive HIV transmission.6 Disparities in rates of HIV among young men who have sex with men present prevention challenges and warrant expanded efforts.
Funding/Support:
The CDC provides funds to all states and the District of Columbia to conduct the HIV surveillance data used in this study.
Footnotes
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Holtgrave reported that Johns Hopkins University received grant support from Johnson & Johnson and the Female Health Company outside of the scope of this article. No other disclosures were reported.
Role of the Sponsor: The CDC had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Publisher's Disclaimer: Disclaimer: The findings and conclusions in this study are those of the authors and do not necessarily represent the views of the CDC.
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