Abstract
Objectives. To report on indicators of the National HIV/AIDS Strategy, we analyzed data collected through the national HIV surveillance system.
Methods. We analyzed data from adults and adolescents aged 13 years or older diagnosed with HIV in 13 US jurisdictions that have laboratory reporting of CD4+ T-lymphocyte (CD4) and viral load (VL) test results and enter CD4 and VL test results into the national surveillance system.
Results. Of 4899 people diagnosed in 2009, 81.7% had at least 1 CD4 or VL test performed within 3 months of diagnosis. A higher proportion of Whites (86.2%) than Blacks (78.4%) and Hispanics (82.6%) had a CD4 or VL test. Of 53 642 people diagnosed through 2008 and living with HIV at the end of 2009 who had a VL test, 69.4% had a most recent VL of 200 copies per milliliter or less. The proportion of people with suppressed VLs differed among Blacks (60.2%), Hispanics (70.3%), and Whites (77.4%) and among people aged 13 to 24 years (44.3%) compared with people aged 65 years or older (84.2%). Of men who have sex with men, 74.2% had a suppressed VL.
Conclusions. The findings highlight disparities in access to and success of care.
In 2010, the White House released the National HIV/AIDS Strategy, centered on reducing new HIV infections, increasing access to care and improving health outcomes for people living with HIV, and reducing HIV-related disparities.1 Specific targets to achieve by 2015 include increasing the proportion of newly diagnosed patients linked to clinical care within 3 months of diagnosis from 65% to 85% and increasing the proportion of HIV-diagnosed gay and bisexual men, Blacks, and Hispanics with undetectable viral loads (VLs) by 20%. HIV surveillance data can be used to monitor the nation’s progress toward the National HIV/AIDS Strategy goals to improve a timely link to care and increase the proportion of HIV-infected people who are virally suppressed.
Successful medical treatment of a person with HIV and the prevention of new infections requires the identification of infection at an early stage of disease, timely linkage to clinical care, prompt initiation of combination antiretroviral therapy when indicated, regular care visits, and adherence to prescribed antiretroviral therapy regimens.2–5 Antiretroviral therapy reduces plasma and genital HIV-1 RNA levels and is associated with reduced probability of HIV transmission.6–9 Patients who adhere to therapy and engage in routine health care are more likely to achieve viral suppression than those who do not see their providers regularly.10 Because the quantity of HIV-1 RNA in plasma is correlated with the risk of HIV-1 transmission, people with suppressed viral loads are less infectious and therefore less likely to transmit HIV infection.7,9
The US Department of Health and Human Services’ Panel on Antiretroviral Guidelines for Adults and Adolescents has recommended CD4+ T-lymphocyte count (CD4) and VL testing for new patients during the initial visit to guide the initiation of treatment.11 To monitor disease status and the response to treatment, VL testing is recommended every 3 to 4 months after HIV diagnosis, and CD4 monitoring should occur at least every 6 to 12 months among patients who are clinically stable.
Data collected through the national HIV surveillance system can be used to monitor key outcomes of the national strategy; however, monitoring outcomes such as linkage to care and racial/ethnic disparities among people who are virally suppressed is particularly dependent on complete reporting of all HIV-related laboratory results, including CD4 and VL results, to surveillance. Although most HIV surveillance jurisdictions have regulations that require laboratories to report CD4 and VL results to health departments, not all areas have mandatory reporting of all levels of CD4 counts and percentages and detectable and undetectable VLs.12 We present findings from an analysis of data collected through the national HIV surveillance system to report on indicators outlined in the national strategy and factors associated with linkage to care and viral suppression.
METHODS
HIV is a mandatory reportable disease in all 50 states; Washington, DC; and 6 US dependent areas. All cases that meet the HIV Surveillance Case Definition13 are reported by state and local health departments to the Centers for Disease Control and Prevention without identifying information. Cases of HIV infection are counted by geographic area on the basis of the person’s residence at earliest known HIV diagnosis. Assessments of duplicate records occur on both the state and the national level, and elimination of such records occurs at the state level.
We used data on adults and adolescents (aged ≥ 13 years) diagnosed with HIV in 13 US jurisdictions (Delaware; Washington, DC; Iowa; Indiana; Kentucky; Missouri; Nebraska; New York State [excluding New York City]; North Dakota; San Francisco, CA; South Carolina; West Virginia; and Wyoming) with mandatory laboratory reporting of CD4 and VL tests and entry of all CD4 and VL test results into the Enhanced HIV/AIDS Reporting System, the national surveillance application. Information was reported to the Centers for Disease Control and Prevention through December 2010.
We compared the demographic differences for the 13 jurisdictions; all states and Washington, DC; and all states with the 13 jurisdictions removed for both new diagnoses and people living with HIV. We then determined linkage to care among people who were diagnosed with HIV in 2009, residents of the 13 areas at the time of diagnosis, and residents who were alive within 3 months after HIV diagnosis. Diagnosis date was based on the month and year of the earliest positive or reactive test reported to the surveillance system; the day of the diagnosis was unknown. People were considered linked to care if they had at least 1 CD4 or VL test performed within 3 months after diagnosis, including CD4 or VL test results that were collected in the same month as the month of diagnosis. We excluded cases from the analysis if they had a missing month for the diagnosis or death date and excluded test results if the month of the sample collection date was missing.
We determined the percentage of people living with HIV with viral suppression among those diagnosed through 2008, aged 13 years or older at the end of 2008, residents of the 13 areas at the time of diagnosis, and living with HIV at the end of 2009. People with a quantitative VL result of 200 copies per milliliter or less or an undetectable VL with a missing quantitative result for the most recent VL in 2009 were classified as virally suppressed (VL ≤ 200 copies/mL). This cut-off value was based on the Department of Health and Human Services–recommended definition of virologic failure with a VL of more than 200 copies per milliliter.11 If multiple VL tests occurred on the same day, we selected the highest VL. We calculated the median, mean, and geometric mean for the subset of people with VL results. Undetectable VLs with missing quantitative results were assigned a value of 1 for the calculation of the geometric mean VL.
We stratified summary analyses by sex, race/ethnicity (Black; Hispanic; White; multiple race, other race, and unknown race), age (13–24, 25–44, 45–64, ≥ 65 years), transmission category (male-to-male sexual contact, injection drug use, male-to-male sexual contact and injection drug use, heterosexual contact, other), country of birth (United States, US dependency, foreign country), and facility type for linkage to care (private physician, hospital inpatient or emergency department, adult HIV clinic, HIV counseling and testing site, sexually transmitted diseases clinic, correctional facility, other clinic). We compared groups with χ2 statistics and calculated prevalence ratios and 95% confidence intervals.
RESULTS
Of 4904 people diagnosed in 2009 in the 13 jurisdictions, 5 (0.1%) had incomplete diagnosis or death dates and were excluded from the analysis. The proportion of people classified as White (36.3%) was higher in the 13 jurisdictions than among those diagnosed in all states and among those diagnosed in states with the 13 jurisdictions removed (29.0% and 28.1%, respectively), whereas the proportion of Hispanics was lower in the 13 areas (10.6% vs 19.4% and 20.5%, respectively; Table 1). Aside from these findings, the demographic distributions for people diagnosed in 2009 in the 13 areas included in this analysis were similar to those of the remainder of the HIV-infected US population. We also generally observed these patterns for people diagnosed through 2008 and people living with HIV at the end of 2009 compared with the remainder of the HIV-infected US population (data not shown).
TABLE 1—
Demographic Characteristics of People Diagnosed With HIV in 2009: National HIV Surveillance System, United States
| Characteristic | 13 US Jurisdictions,a No. (%) | All States and Washington, DC, No. (%) | All States (With the 13 Jurisdictions Removed), No. (%) |
| Sex | |||
| Male | 3809 (77.8) | 33 622 (77.1) | 29 813 (77.0) |
| Female | 1090 (22.2) | 9987 (22.9) | 8897 (23.0) |
| Age at diagnosis, y | |||
| 13–24 | 956 (19.5) | 8539 (9.6) | 7583 (19.6) |
| 25–44 | 2549 (52.0) | 23 122 (53.0) | 20 573 (53.1) |
| 45–64 | 1305 (26.6) | 11 268 (25.8) | 9963 (25.7) |
| ≥ 65 | 89 (1.8) | 680 (1.6) | 591 (1.5) |
| Race/ethnicity | |||
| Black | 2417 (49.3) | 20 978 (48.1) | 18 561 (47.9) |
| Hispanic | 518 (10.6) | 8463 (19.4) | 7945 (20.5) |
| White | 1778 (36.3) | 12 655 (29.0) | 10 877 (28.1) |
| Otherb | 186 (3.8) | 1513 (3.5) | 1327 (3.4) |
| Transmission category | |||
| Male-to-male sexual contact | 2367 (48.3) | 20 249 (46.4) | 17 882 (46.2) |
| Injection drug use, males | 181 (3.7) | 1342 (3.1) | 1161 (3.0) |
| Injection drug use, females | 101 (2.1) | 817 (1.9) | 716 (1.8) |
| Male-to-male sexual contact and injection drug use | 146 (3.0) | 1002 (2.3) | 856 (2.2) |
| Heterosexual contact,c males | 318 (6.5) | 2820 (6.5) | 2502 (6.5) |
| Heterosexual contact,c females | 500 (10.2) | 4274 (9.8) | 3774 (9.7) |
| Other/unknown, males | 797 (16.3) | 8209 (18.8) | 7412 (19.1) |
| Other/unknown, females | 489 (10.0) | 4896 (11.2) | 4407 (11.4) |
| Total | 4899 (100) | 43 609 (100) | 38 710 (100) |
The 13 US jurisdictions included were DE; Washington, DC; IA; IN; KY; MO; NE; NY [excluding New York City]; ND; San Francisco, CA; SC; WV; and WY.
Multiple race, American Indian/Alaska Native, Asian, Native Hawaiian/Other Pacific Islander, and unknown race.
cHeterosexual contact with a person known to have or to be at high risk for HIV infection.
Among the 4899 people diagnosed in 2009 and included in this analysis, 81.7% had at least 1 CD4 or VL test performed within 3 months of diagnosis (Table 2). A higher proportion of Whites (86.2%) than Blacks (78.4%; P < .001) and Hispanics (82.6%; P = .045) had a CD4 or VL test. The proportion of people with a CD4 or VL test was also higher among females (84.1%; P = .019) than among males (81.0%) and among people aged 65 years or older (92.1%; P < .001) compared with people aged 13 to 24 years (74.6%). Compared with heterosexual women (87.8%), fewer men who have sex with men (82.4%; P = .003) and men exposed through heterosexual contact (82.1%; P = .023) had a CD4 or VL test result. Although the actual count for foreign-born people was relatively small, a larger proportion of foreign-born people (85.6%; P = .012) than of US-born people (80.5%) had CD4 or VL test results. The proportion of people with a CD4 or VL test was high among those diagnosed in emergency departments or hospital inpatient facilities (89.5%) and by private physicians (87.7%). People diagnosed in sexually transmitted disease clinics (60.0%; P < .001) and at HIV counseling and testing sites (64.5%; P < .001) were less likely to have a CD4 or VL test than those diagnosed by a private physician.
TABLE 2—
Number and Percentage of People With a CD4 or Viral Load Test Performed Within 3 Months of HIV Diagnosis Among People Diagnosed With HIV in 2009: National HIV Surveillance System, 13 US Jurisdictions
| Characteristic | Total,a No. (%b) | CD4 Only, No. (%) | VL Only, No. (%) | CD4 and VL, No. (%) | ≥ 1 CD4 or VL test,c No. (%) | P | PRd (95% CI) |
| Sex | |||||||
| Male | 3809 (77.8) | 246 (6.5) | 324 (8.5) | 2516 (66.1) | 3086 (81.0) | ||
| Female | 1090 (22.2) | 69 (6.3) | 100 (9.2) | 748 (68.6) | 917 (84.1) | .019 | |
| Age at diagnosis, y | |||||||
| 13–24 | 956 (19.5) | 36 (3.8) | 80 (8.4) | 597 (62.4) | 713 (74.6) | 1.00 (Ref) | |
| 25–44 | 2549 (52.0) | 158 (6.2) | 227 (8.9) | 1700 (66.7) | 2085 (81.8) | < .001 | 1.10 (1.05, 1.14) |
| 45–64 | 1305 (26.6) | 109 (8.4) | 114 (8.7) | 900 (69.0) | 1123 (86.1) | < .001 | 1.15 (1.11, 1.20) |
| ≥ 65 | 89 (1.8) | 12 (13.5) | 3 (3.4) | 67 (75.3) | 82 (92.1) | < .001 | 1.24 (1.15, 1.33) |
| Race/ethnicity | |||||||
| Black | 2417 (49.3) | 175 (7.2) | 192 (7.9) | 1529 (63.3) | 1896 (78.4) | < .001 | 0.91 (0.89, 0.94) |
| Hispanic | 518 (10.6) | 32 (6.2) | 39 (7.5) | 357 (68.9) | 428 (82.6) | .045 | 0.96 (0.92, 1.00) |
| White | 1778 (36.3) | 100 (5.6) | 181 (10.2) | 1251 (70.4) | 1532 (86.2) | 1.00 (Ref) | |
| Othere | 186 (3.8) | 8 (4.3) | 12 (6.5) | 127 (68.3) | 147 (79.0) | .009 | 0.92 (0.85, 0.99) |
| Transmission category | |||||||
| Male-to-male sexual contact | 2367 (48.3) | 117 (9) | 206 (8.7) | 1628 (68.8) | 1951 (82.4) | .003 | 0.94 (0.90, 0.97) |
| Injection drug use, males | 181 (3.7) | 20 (11.0) | 9 (5.0) | 129 (71.3) | 158 (87.3) | .859 | 0.99 (0.93, 1.06) |
| Injection drug use, females | 101 (2.1) | 6 (5.9) | 5 (5.0) | 73 (72.3) | 84 (83.2) | .206 | 0.95 (0.86, 1.04) |
| Male-to-male sexual contact and injection drug use | 146 (3.0) | 9 (6.2) | 11 (7.5) | 97 (66.4) | 117 (80.1) | .019 | 0.91 (0.84, 1.00) |
| Heterosexual contact,f males | 318 (6.5) | 22 (6.9) | 18 (5.7) | 221 (69.5) | 261 (82.1) | .023 | 0.93 (0.88, 0.99) |
| Heterosexual contact,f females | 500 (10.2) | 32 (6.4) | 45 (9.0) | 362 (72.4) | 439 (87.8) | 1.00 (Ref) | |
| Other/unknown, males | 797 (16.3) | 78 (9.8) | 80 (10.0) | 441 (55.3) | 599 (75.2) | < .001 | 0.86 (0.81, 0.90) |
| Other/unknown, females | 489 (10.0) | 31 (6.3) | 50 (10.2) | 313 (64.0) | 394 (80.6) | .002 | 0.92 (0.87, 0.97) |
| Country of birth | |||||||
| United States | 3440 (70.2) | 229 (6.7) | 325 (9.4) | 2216 (64.4) | 2770 (80.5) | 1.00 (Ref) | |
| US dependency | 18 (0.4) | 0 (0) | 2 (11.1) | 15 (83.3) | 17 (94.4) | .136 | 1.17 (1.05, 1.31) |
| Foreign country | 411 (8.4) | 30 (7.3) | 26 (6.3) | 296 (72.0) | 352 (85.6) | .012 | 1.06 (1.02, 1.11) |
| Missing or unknown | 1030 (21.0) | 56 (5.4) | 71 (6.9) | 737 (71.6) | 864 (83.9) | .015 | 1.04 (1.01, 1.07) |
| Type of facility | |||||||
| Private physician or HMO | 876 (17.9) | 50 (5.7) | 97 (11.1) | 621 (70.9) | 768 (87.7) | 1.00 (Ref) | |
| Emergency room or inpatient clinic | 870 (17.8) | 98 (11.3) | 55 (6.3) | 626 (72.0) | 779 (89.5) | .219 | 1.02 (0.99, 1.06) |
| Adult HIV clinic | 289 (5.9) | 16 (5.5) | 16 (5.5) | 210 (72.7) | 242 (83.7) | .088 | 0.96 (0.90, 1.01) |
| HIV counseling and testing site | 372 (7.6) | 9 (2.4) | 30 (8.1) | 201 (54.0) | 240 (64.5) | < .001 | 0.74 (0.68, 0.80) |
| STD clinic | 215 (4.4) | 2 (0.9) | 35 (16.3) | 92 (42.8) | 129 (60.0) | < .001 | 0.68 (0.61, 0.77) |
| Correctional facility | 196 (4.0) | 17 (8.7) | 10 (5.1) | 135 (68.9) | 162 (82.7) | .061 | 0.94 (0.88, 1.01) |
| Other clinic | 756 (15.4) | 48 (6.3) | 61 (8.1) | 471 (62.3) | 580 (76.7) | < .001 | 0.88 (0.84, 0.92) |
| Unknown | 1325 (27.0) | 75 (5.7) | 120 (9.1) | 908 (68.5) | 1103 (83.2) | .004 | 0.95 (0.92, 0.98) |
| Total | 4899 (100 | 315 (6.4) | 424 (8.7) | 3264 (66.6) | 4003 (81.7) |
Note. CD4 = CD4+ T-lymphocyte count (cells/μL) or percentage; CI = confidence interval; HMO = health maintenance organization; PR = prevalence ratio; STD = sexually transmitted disease; VL = viral load (copies/mL). The 13 US jurisdictions included were DE; Washington, DC; IA; IN; KY; MO; NE; NY [excluding New York City]; ND; San Francisco, CA; SC; WV; and WY. P values were determined by the χ2 test.
Because row totals for numbers were calculated independently of the values for the subpopulations, the values in each row may not sum to the row total.
The total percentage represents the column percentage.
≥ 1 CD4 or VL test is not included in the row total.
Calculated on the probability of people with ≥ 1 CD4 or VL test within 3 months with univariate binomial regression.
Multiple race, American Indian/Alaska Native, Asian, Native Hawaiian/Other Pacific Islander, and unknown race.
Heterosexual contact with a person known to have or to be at high risk for HIV infection.
Of 100 375 people diagnosed through 2008 and living with HIV at the end of 2009, valid VL data were available for 53.4% (Table 3). In the overall population, including people who had no VL testing reported, 37.1% had a VL of 200 copies per milliliter or less. The proportion of Blacks (29.9%; P < .001) and Hispanics (32.7%; P < .001) with suppressed VLs was lower than that among Whites (45.3%). The proportion with suppressed VLs was also lower among people aged 13 to 24 years (25.4%) than among people aged 65 years and older (38.1%; P < .001). The proportion of men having sex with men with VLs of 200 copies per milliliter or less was 42.7%.
TABLE 3—
Number and Percentage of People With HIV Viral Suppression Among People Diagnosed Through 2008 and Living With HIV at the End of 2009: National HIV Surveillance System, 13 US Jurisdictions
| Among People With a VL Test |
VL ≤ 200 (Among Overall Population) |
VL ≤ 200 (Among People With a VL Test) |
||||||||
| Characteristic | Total,a No. (%b) | No. (%) | Geometric Mean VL | VL ≤ 200 No. | % | P | PRc (95% CI) | % | P | PRc (95% CI) |
| Sex | ||||||||||
| Male | 76 888 (76.6) | 40 578 (52.8) | 180 | 28 952 | 37.7 | 71.3 | ||||
| Female | 23 487 (23.4) | 13 064 (55.6) | 267 | 8256 | 35.2 | < .001 | 63.2 | < .001 | ||
| Age at end of 2008, y | ||||||||||
| 13–24 | 3672 (3.7) | 2102 (57.2) | 757 | 932 | 25.4 | 1.00 (Ref) | 44.3 | 1.00 (Ref) | ||
| 25–44 | 43 256 (43.1) | 23 386 (54.1) | 287 | 14 799 | 34.2 | < .001 | 1.25 (1.18, 1.32) | 63.3 | < .001 | 1.39 (1.33, 1.46) |
| 45–64 | 50 126 (49.9) | 26 650 (53.2) | 134 | 20 211 | 40.3 | < .001 | 1.51 (1.42, 1.59) | 75.8 | < .001 | 1.66 (1.58, 1.74) |
| ≥ 65 | 3321 (3.3) | 1504 (45.3) | 88 | 1266 | 38.1 | < .001 | 1.43 (1.33, 1.53) | 84.2 | < .001 | 1.77 (1.68, 1.86) |
| Race/ethnicity | ||||||||||
| Black | 44 410 (44.2) | 22 029 (49.6) | 335 | 13 269 | 29.9 | < .001 | 0.71 (0.70, 0.73) | 60.2 | < .001 | 0.82 (0.81, 0.83) |
| Hispanic | 12 181 (12.1) | 5660 (46.5) | 164 | 3981 | 32.7 | < .001 | 0.83 (0.81, 0.86) | 70.3 | < .001 | 0.93 (0.92, 0.95) |
| White | 40 188 (40.0) | 23 545 (58.6) | 131 | 18 218 | 45.3 | 1.00 (Ref) | 77.4 | 1.00 (Ref) | ||
| Otherd | 3596 (3.6) | 2408 (67.0) | 147 | 1740 | 48.4 | < .001 | 1.14 (1.10, 1.18) | 72.3 | < .001 | 0.96 (0.94, 0.99) |
| Transmission category | ||||||||||
| Male-to-male sexual contact | 44 359 (44.2) | 25 556 (57.6) | 158 | 18 950 | 42.7 | < .001 | 0.98 (0.96, 1.01) | 74.2 | < .001 | 1.07 (1.05, 1.09) |
| Injection drug use, males | 9949 (9.9) | 4230 (42.5) | 226 | 2749 | 27.6 | < .001 | 0.69 (0.66, 0.72) | 65.0 | .173 | 0.96 (0.93, 0.98) |
| Injection drug use, females | 5192 (5.2) | 2711 (52.2) | 302 | 1644 | 31.7 | < .001 | 0.79 (0.75, 0.83) | 60.6 | .004 | 0.92 (0.89, 0.95) |
| Male-to-male sexual contact and injection drug use | 6114 (6.1) | 3529 (57.7) | 215 | 2353 | 38.5 | .625 | 0.88 (0.85, 0.92) | 66.7 | .003 | 0.96 (0.94, 0.99) |
| Heterosexual contact,e males | 5924 (5.9) | 3116 (52.6) | 260 | 2044 | 34.5 | < .001 | 0.91 (0.88, 0.95) | 65.6 | .068 | 1.02 (0.99, 1.05) |
| Heterosexual contact,e females | 12 313 (12.3) | 7364 (59.8) | 257 | 4693 | 38.1 | 1.00 (Ref) | 63.7 | 1.00 (Ref) | ||
| Other/unknown, males | 10 542 (10.5) | 4147 (39.3) | 207 | 2856 | 27.1 | < .001 | 0.70 (0.68, 0.73) | 68.9 | < .001 | 1.06 (1.03, 1.08) |
| Other/unknown, females | 5982 (6.0) | 2989 (50.0) | 261 | 1919 | 32.1 | < .001 | 0.88 (0.84, 0.92) | 64.2 | .65 | 1.04 (1.01, 1.07) |
| Country of birth | ||||||||||
| United States | 72 669 (72.4) | 40 403 (55.6) | 214 | 27 843 | 38.3 | 1.00 (Ref) | 68.9 | 1.00 (Ref) | ||
| US dependency | 1283 (1.3) | 450 (35.1) | 212 | 295 | 23.0 | < .001 | 0.69 (0.63, 0.77) | 65.6 | .126 | 0.96 (0.90, 1.03) |
| Foreign country | 6527 (6.5) | 3191 (48.9) | 128 | 2349 | 36.0 | .000 | 0.97 (0.94, 1.01) | 73.6 | < .001 | 1.07 (1.04, 1.09) |
| Missing or unknown | 19 896 (19.8) | 9598 (48.2) | 162 | 6721 | 33.8 | < .001 | 0.93 (0.91, 0.95) | 70.0 | .034 | 1.01 (1.00, 1.03) |
| Total | 100 375 (100) | 53 642 (53.4) | 198 | 37 208 | 37.1 | 69.4 | ||||
Note. CI = confidence interval; PR = prevalence ratio; VL = viral load (copies/mL). The 13 US jurisdictions included were DE; Washington, DC; IA; IN; KY; MO; NE; NY [excluding New York City]; ND; San Francisco, CA; SC; WV; and WY. P values were determined by the χ2 test.
Because row totals for numbers were calculated independently of the values for the subpopulations, the values in each row may not sum to the row total.
The total percentage represents the column percentage.
Calculated on the probability of having a suppressed VL (≤ 200 copies/mL) with multivariate binomial regression.
Multiple race, American Indian/Alaska Native, Asian, Native Hawaiian/Other Pacific Islander, and unknown race.
Heterosexual contact with person known to have or to be at high risk for HIV infection.
Of people who had a VL test reported (n = 53 642), the mean and geometric mean were 22 708 copies per milliliter and 198 copies per milliliter, respectively, and 69.4% had a VL of 200 copies per milliliter or less. The proportion of Blacks (60.2%; P < .001) and Hispanics (70.3%; P < .001) with suppressed VLs was lower than among Whites (77.4%). The proportion with suppressed VLs was also lower among people aged 13 to 24 years (44.3%) than among people aged 65 years and older (84.2%; P < .001). The geometric mean VL at the most recent visit was lower among people aged 65 years or older (88 copies/mL) than among people aged 13 to 24 years (757 copies/mL) and lower among Whites (131 copies/mL) than among Blacks (335 copies/mL). Compared with heterosexual women (63.7%), more men who have sex with men (74.2%; P < .001) and men exposed through heterosexual contact (65.6%; P = .068) had a VL of 200 copies per milliliter or less. Although country of birth was missing for 20% of this population, a larger proportion of foreign-born people (73.6; P < .001) than US-born people (68.9%) had suppressed VLs.
Because people may relocate after diagnosis, we assessed viral suppression among those with no evidence of relocation. When we excluded cases with evidence of duplicate reports, the proportion of people with a suppressed VL, among those with a VL test, increased slightly from 69.4% to 70.6%.
DISCUSSION
Our findings indicate that 82% of newly diagnosed people were linked to care within 3 months of diagnosis. This estimate is higher than that assumed as the baseline in the National HIV/AIDS Strategy; however, it was based on data from 13 of the 65 jurisdictions that report HIV surveillance data to the Centers for Disease Control and Prevention, representing 11.2% of all people diagnosed in 2009 in the 50 US states and Washington, DC. Linkage to care varied by transmission risk and was lower among Blacks and Hispanics than among Whites and among younger people than among people aged 25 years and older. These findings are consistent with those of other studies that have documented disparities in health care utilization for HIV.14–18
Data on treatment are not available in the national surveillance dataset, so we were not able to assess the relationship between antiretroviral therapy and viral suppression. Instead, we measured viral suppression among people living with HIV. The data analyzed represented 12.4% of all people diagnosed through 2008 and living with HIV at the end of 2009 in the 50 US states and Washington, DC. Among those in care with a viral load, viral suppression was high (69%) and observed in 74% of men who have sex with men, 60% of Blacks, and 70% of Hispanics, highlighting disparities among the National HIV/AIDS Strategy priority groups. The implementation of effective interventions is needed to meet the National HIV/AIDS Strategy goal of increasing the proportion of HIV-diagnosed gay and bisexual men, Blacks, and Hispanics with undetectable VLs by 20%.
Diagnosing HIV early in the course of infection substantially reduces the risk of further transmission, morbidity, and mortality. However, early linkage to care and longitudinal retention are essential to realizing these benefits and present significant opportunities for maximizing individual health outcomes. Delayed linkage to care has been associated with postponed initiation of antiretroviral therapy, virologic failure, advanced infection, and decreased quality of life and rate of survival.2,14,15 Beyond the impact on individual patient health, prompt initiation of medical care can decrease transmission risk by reducing infectiousness among those with suppressed viremia. Moreover, early linkage to care allows the full public health benefits to be realized by providing opportunities for additional HIV prevention activities such as counseling, condom distribution, and education regarding risk behaviors.19–21 Although early linkage to care is an important first step, retention in care is also critical. A recent analysis showed that of an estimated 942 000 people with HIV who were aware of their infection, approximately 77% were linked to care within 3 to 4 months of diagnosis, yet only 51% remained in ongoing care.22
The US Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents has recommended regular monitoring of disease status and treatment response in HIV-1 infected patients, with CD4 and VL results determined every 3 to 12 months depending on the patient’s clinical stability.11 People living with HIV without CD4 or VL testing after HIV diagnosis are people with unmet health care needs. The reasons that newly diagnosed people may not successfully access health care are often complex but include unsuccessful patient notification of positive HIV test results,23–25 lack of health insurance coverage,26,27 denial,28,29 and substance abuse or mental health problems.30,31 Other social and economic determinants of health such as poverty, homelessness, unemployment, lack of transportation, and lower education may also affect linkage to and retention in care.31,32
The ability to use CD4 and VL test results to monitor outcomes at the national level is dependent on the completeness and quality of laboratory data reported to the national surveillance system. Completeness of data can be enhanced by revising state regulations to require the reporting of all levels of CD4 results (counts and percentages) and all VL results (detectable and undetectable). Surveillance programs should actively monitor the volume of laboratory results received, the number of providers reporting to them, and the quality of data being reported. The implementation of electronic laboratory reporting can help to streamline the flow of laboratory data and reduce data quality errors. To ensure that all laboratory results are reported to surveillance at the national level, state and local surveillance programs must enter all laboratory results received into the Enhanced HIV/AIDS Reporting System for transmission to the Centers for Disease Control and Prevention.
Several limitations should be considered when interpreting our findings. This analysis was based on data from a limited number of areas with mandatory laboratory reporting of CD4 and VL tests and reporting of all CD4 and VL tests to national HIV surveillance. As additional areas improve the reporting of laboratory data to the Centers for Disease Control and Prevention, future estimates of linkage to care and the proportion of people in care with viral suppression will be more representative. Information was not available on care visits that did not result in a CD4 or VL lab test. If lab data reported to surveillance are incomplete, the methods outlined may underestimate the proportion of people who entered care. Alternatively, we could have overestimated the proportion of people linked to medical care because we included those who received a lab test in the same month as the HIV diagnosis. For example, people diagnosed in an urgent care facility or emergency department who had lab tests ordered at the time of diagnosis but who did not enter care for HIV after their discharge would be included in this analysis. This analysis included people living with HIV in the 13 areas at the time of diagnosis; however, although patients may have relocated since diagnosis and received clinical care in another jurisdiction, results were similar when using information available in surveillance data on relocation. In addition, results based on people living with HIV may also be affected by delays in the reporting of death information.
In summary, the completeness and quality of HIV surveillance data are critical for monitoring progress toward the goals of the National HIV/AIDS Strategy. Monitoring outcomes such as linkage to care and disparities among people who are virally suppressed is particularly dependent on complete reporting of all HIV-related laboratory results to surveillance. In this analysis, we found that about 20% of people did not enter care within 3 months of diagnosis and about 30% of people living with HIV were not virally suppressed. We also observed disparities across race/ethnicity, age, sex, and risk groups among people who are linked to clinical care and virally suppressed. Further work needs to identify and address barriers to prompt utilization of care across all populations.
Acknowledgments
An abstract of this article was presented at the 2011 National HIV Prevention Conference, August 15, 2011, Atlanta, GA.
Human Participant Protection
This study used data collected as part of routine public health disease surveillance. It has been determined that public health surveillance is not research. No protocol approval was needed for this study.
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