RESEARCH ARTICLE


Trends in Care and Treatment for Persons Aged ≥13 Years with HIV Infection 17 U.S. Jurisdictions, 2012-2015



Debra L. Karch1, *, Xueyuan Dong2, Jing Shi2, H. I. Hall1
1 HIV Incidence and Case Surveillance Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS E-47, Atlanta, GA 30329, U.S
2 ICF International, Inc, Atlanta, GA, U.S


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© 2018 Karch et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the HIV Incidence and Case Surveillance Branch, Division of HIV Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS E-47, Atlanta, GA 30329, U.S; Tel: (404) 639-5174; E-mail: DKarch@cdc.gov


Abstract

Background:

Care and viral suppression national goals for HIV infection are not being met for many at-risk groups. Assessment of the trends in national outcomes for linkage to care, receipt of care, and viral suppression among these groups is necessary to reduce transmission.

Methods:

Data reported to the National HIV Surveillance System by December 2016 were used to identify cases of HIV infection among persons aged 13 years and older in one of 17 identified jurisdictions with complete laboratory reporting. We estimated national trends in HIV-related linkage to care, receipt of care and viral suppression using estimated annual percent change from 2012-2015 for various characteristics of interest, overall and stratified by sex and race/ethnicity.

Results:

Overall, trends in linkage to and receipt of care and viral suppression increased from 2012-2015. Generally, linkage to and receipt of care increased among young black and Hispanic/Latino males, those with infection attributed to male-to-male sexual contact, and those not in stage 3 [AIDS] at HIV diagnosis. All sub-groups showed improvement in viral suppression. Within years, there remains a substantial disparity in receipt of care and viral suppression among racial/ethnic groups.

Conclusion:

While trends are encouraging, scientifically proven prevention programs targeted to high-risk populations are the foundation for stopping transmission of HIV infection. Frequent testing to support early diagnosis and prompt linkage to medical care, particularly among young men who have male to male sexual contact, black and Hispanic/Latino populations, are key to reducing transmission at all stages of disease.

Keywords: HIV Infection, Trend, Linkage, Treatment, Viral Suppression, CD4.



1. INTRODUCTION

In the United States, between 2010 and 2014 the rate of people living with HIV steadily increased from 275.7/100,000 population to 299.5/100,000 population, respectively. In 2010, the rate of HIV diagnoses was 14.2/100,000 population and the rate declined to 12.3/100,000 population in 2015 [1]. The highest rates of new diagnoses in 2015 were among blacks/African Americans (hereafter referred to as blacks) (44.3/100,000 population), more specifically black males (84.8/100,000 population), blacks aged 20-24 years (111.2/100,000 population) and blacks 25-29 years (112.2/100,000 population) [1]. Hispanics/Latinos also experienced elevated rates of HIV diagnoses over whites although the rates remained at approximately one-third to one-half the rates of blacks with the same sex and age characteristics. The vast majority of males with HIV infection diagnosed in 2015 had infection attributed to male-to-male sexual contact or male-to-male sexual contact in conjunction with injection drug use (86.2%); females had infection attributed primarily to heterosexual contact (86.3%) [1]. For these and other risk groups, prevention services are essential to avoid further spread of HIV infection and, for those living with HIV infection, coordinated supportive services and medical care are crucial [2].

Goals of the National HIV/AIDS strategy for the United States: Updated to 2020 [3] include reducing new HIV infections, increasing access to care and improving health outcomes for people living with HIV infection, reducing HIV-related disparities and health inequities, and achieving a more coordinated national response to the HIV epidemic. Progress toward these goals by 2020 includes: increasing to 85% the number of newly diagnosed persons who are linked to HIV medical care within one month of diagnosis, increasing to 90% the number of persons living with diagnosed HIV who are retained in HIV medical care, increasing to 80% the number of persons diagnosed with HIV who have suppressed viral load, and reducing disparities by focusing on high risk groups comprised of young black gay and bisexual males and black females [4] for whom disparities in HIV diagnoses and treatment outcomes have been demonstrated [5-8].

Data from the National HIV Surveillance System, described elsewhere [9, 10], show that for people with HIV infection diagnosed in 2015 in 37 states and the District of Columbia, 75.0% were linked to care within one month of diagnosis and for those with HIV diagnosed by year-end 2013 and alive at year-end 2014, 72.5% were retained in care and 57.9% had suppressed viral load [11]. All three indicators fall short of national goals. In 2014, for 32 states and the District of Columbia, outcomes for these three indicators were even lower for black males (69.9%, 67.0%, and 47.9% respectively), males aged 18-24 years (66.2%, 71.4%, and 44.4% respectively), and people who inject drugs (74.3%, 64.3%, and 47.1% respectively) [12].

Assessing changes in linkage to care, received care, and viral suppression over the last decade has been hindered by a lack of comprehensive HIV laboratory reporting laws that require reporting of all CD4 results regardless of value and all viral load results including detectable and undetectable; and by incomplete laboratory reporting within states with comprehensive reporting laws [13]. This study examined annual changes for 2012 to 2015 in linkage to care, receipt of care, and viral suppression among adults and adolescents using data reported for 17 jurisdictions to the National HIV Surveillance System. These jurisdictions represented approximately 46% of the U.S. population. We aimed to explore these changes by patient characteristics, stage of HIV infection at diagnosis and transmission category.

2. METHODS

Data reported to the National HIV Surveillance System by December 2016 were used to identify cases of HIV infection that met the CDC HIV infection case definition [14] among persons aged 13 years and older at time of diagnosis and whose residence at diagnosis (for linkage to care) and most current residence (for receipt of care and viral suppression) were within one of 17 identified jurisdictions with complete laboratory reporting. To be eligible for inclusion jurisdictions were required to meet the following three criteria for each year between 2012 and 2015:

  • The jurisdiction’s laws/regulations required the reporting of all CD4 and viral load results to the state/city health department,
  • Laboratories that perform HIV-related testing for the areas must have reported a minimum of 95% of HIV-related test results to the state/city health department, and
  • By December 31, 2016, the area had reported to CDC at least 95% of all CD4 and viral load test results received from January 2012 through December 2015.

The jurisdictions that met inclusion criteria were California, District of Columbia, Hawaii, Iowa, Illinois, Indiana, Louisiana, Maryland, Michigan, Missouri, New Hampshire, New York, North Dakota, South Carolina, Texas, Utah, and West Virginia.

Linkage-to-care analysis included people with HIV infection diagnosed between January 1st and December 31st of the outcome year (e.g., the outcome for 2012 includes all diagnoses between January 1, 2012 and December 31, 2012). Linkage to care was defined as ≥1 CD4 or viral load test performed within 1 month of diagnosis.

Receipt of care and viral load suppression analyses included people with HIV diagnosed before January 1st of the outcome year and not known to be deceased on December 31st of the outcome year (e.g., the result for 2012 includes all persons with an HIV diagnosis before January 1, 2012 and not known to be deceased on December 31, 2012). Receipt of care was defined as ≥1 CD4 or viral load test performed during the outcome year. Viral suppression was defined as a viral load result of <200 copies/mL or, if the quantitative value was missing, a test interpretation value of “undetected”, at the time of the most recent viral load test during the outcome year.

Laboratory results with missing month or year of specimen collection were excluded from the analysis (<0.36% for linkage-to-care and <0.16% for receipt of care and viral suppression). All duration times were calculated using the month and year for both HIV infection diagnosis and laboratory results. If a patient had two tests in the same month with different viral suppression results, we applied a conservative approach and used the test result that indicated a higher viral load. In addition, laboratory tests with a missing result and tests with specimen collection dates prior to the date of HIV infection diagnosis were excluded.

The twelve-month interval between the last observation year (2015) and dataset used (reporting through December 2016) allowed time for reporting of diagnoses, laboratory results, and deaths. Data were adjusted for unknown or missing transmission category [15]. Results are presented by age group (13-24, 25-34, 35-44, 45-54, ≥55), sex, race/ethnicity (black, Hispanic/Latino, white, and other) (those with missing race/ethnicity were excluded from the analysis), and transmission category (male-to-male sexual contact, people who inject drugs, male-to-male sexual contact and injection drug use, heterosexual contact, and other). Stage of disease at diagnosis was categorized as diagnosis of HIV-infection Stage 3 [AIDS] within 3 months of an HIV diagnosis, or the absence of HIV-infection Stage 3 [AIDS] diagnosis within 3 months of an HIV diagnosis. The estimated annual percent change (EAPC) was calculated for each person characteristic and considered statistically significant at P-value <.05. All analyses were conducted using SAS 9.3 (SAS Institute, Inc., Cary, NC). This project was approved by CDC as a retrospective, secondary data analysis using HIV surveillance data. This analysis did not constitute research involving identifiable human subjects requiring IRB review.

3. RESULTS

Linkage to care among the 81,174 (2012=20,876; 2013=19,887; 2014=20,467; and 2015=19,944) people with HIV infection diagnosed between January 1, 2012 and December 31, 2015 increased each year from 2012-2015 (79.9%, 81.4%, 82.9%, and 83.7% respectively, EAPC = 1.6, 95% CI 0.9-2.3, P<.001) (Table 1). In 2015, linkage to care was higher among whites compared with all other races/ethnicities, older age groups compared with younger age groups, and those with HIV-infection Stage 3 [AIDS] compared with those without stage 3 [AIDS] diagnosis. Linkage was also higher among women and those with infection attributed to heterosexual contact. Linkage to care increased significantly from 2012-2015 among males (EAPC=1.6, 95% CI 0.9-2.4, P<.001), blacks (EAPC=2.2, 95% CI 1.1-3.3, P<.001), those with HIV diagnosed earlier than stage 3 (AIDS) (EAPC=2.4, 95% CI 1.6-3.2, P<.001), males with infection attributed to male-to-male sexual contact (EAPC=1.6, 95% CI 0.7-2.4, P<.001), those aged 13-24, 25-34, and 35-44 years at diagnosis (EAPC=3.2, 95% CI 1.7-4.7, P<.001, EAPC=1.3, 95% CI 0.1-2.5, P=.039, and EAPC=1.7, 95% CI 0.2-3.2, P=.031 respectively), and those with a transmission category of heterosexual contact (EAPC=1.8, 95% CI 0.4-3.3, P=.014).

Table 1. Linkage to care among persons aged ≥13 years with HIV diagnosed during 2012-2015, by selected characteristics -- 17 US jurisdictionsa
Characteristic Total Linked to careb for persons diagnosed in the year   Trends from 2012 - 2015
2012 2013 2014 2015 EAPC 95% CI P-value
(N=20,876) (N=19,887) (N=20,467) (N=19,944)
No. (%) No. (%) No. (%) No. (%) Lower Upper
Sex                          
      Male 66,312 13,464 79.6 13,150 81.0 13,822 82.5 13,693 83.5 1.6 0.9 2.4 <.001
      Female 14,862 3,206 81.1 3,047 83.3 3,137 84.5 3,002 84.8 1.5 -0.1 3.1 0.068
Race/Ethnicity                          
      Black/African American 33,116 6,499 75.8 6,398 78.2 6,686 80.5 6,506 80.8 2.2 1.1 3.3 <.001
      Hispanic/Latino 22,751 4,577 80.1 4,511 82.6 4,807 82.5 4,802 83.6 1.3 0.0 2.6 0.055
      White 19,825 4,408 85.7 4,154 85.7 4,285 86.3 4,280 87.9 0.8 -0.5 2.2 0.228
      Other 5,482 1,186 81.9 1,134 81.6 1,181 86.3 1,107 86.7 2.3 -0.3 5.0 0.087
Age group at diagnosis                          
      13-24 18,434 3,504 74.3 3,484 77.8 3,711 78.4 3,710 82.3 3.2 1.7 4.7 <.001
      25-34 26,026 5,056 79.4 5,012 80.2 5,474 82.4 5,556 82.2 1.3 0.1 2.5 0.039
      35-44 16,418 3,510 80.7 3,371 83.7 3,525 84.5 3,286 84.9 1.7 0.2 3.2 0.031
      45-54 13,057 3,045 84.3 2,759 84.7 2,683 86.1 2,642 86.1 0.8 -0.9 2.5 0.345
      55+ 7,239 1,555 84.9 1,571 83.8 1,566 87.0 1,501 86.6 1 -1.3 3.2 0.406
Stage at diagnosis                          
      HIV infection stage 3(AIDS) 18,072 4,805 98.6 4,471 98.8 4,429 99.1 4,177 99.4 0.3 -1.0 1.6 0.693
      Not known to be HIV infection stage 3 63,102 11,865 74.1 11,726 76.3 12,530 78.3 12,518 79.5 2.4 1.6 3.2 <.001
Transmission Categoryc                          
      Male-to-male sexual contact 55,276 11,138 79.7 10,904 81.2 11,677 82.7 11,490 83.5 1.6 0.7 2.4 <.001
      Injection drug use 5,010 1,054 77.4 934 77.2 904 79.9 1,046 80.1 1.3 -1.4 4.1 0.341
      Male-to-male sexual contact and injection drug Use 2,646 596 81.1 533 79.4 530 82.2 504 84.7 1.6 -2.2 5.5 0.422
      Heterosexual contactd 18,068 3,842 80.7 3,787 83.4 3,821 84.5 3,622 85.3 1.8 0.4 3.3 0.014
      Othere 174 40 78.5 39 83.9 27 69.0 33 84.8 0.5 -13.4 16.5 0.952
Total 81,174 16,670 79.9 16,197 81.4 16,959 82.9 16,695 83.7 1.6 0.9 2.3 <.001
Abbreviations: HIV= Human Immunodeficiency Virus, EAPC=Estimated Annual Percent Change. Note: The denominator for each characteristic for each year are not presented. aJurisdictions include California, District of Columbia, Hawaii, Iowa, Illinois, Indiana, Louisiana, Maryland, Michigan, Missouri, New Hampshire, New York, North Dakota, South Carolina, Texas, Utah, and West Virginia. bDefined as one or more CD4+ T-lymphocyte or viral load test within 1 month after HIV diagnosis. cData statistically adjusted to account for missing transmission categories. dHeterosexual contact with a person known to have, or to be at high risk for, HIV infection. eIncludes hemophilia, blood transfusion, perinatal exposure and risk factor not reported or not identified.

By race/ethnicity and sex, linkage to care increased among black males overall (EAPC=2.5, 95% CI 1.2-3.8, P<0.001), and specifically among black males aged 13-24 years (EAPC=3.4, 95% CI 1.1-5.8, P=0.004), those in earlier than stage 3 of the disease at diagnosis (EAPC=3.8, 95% CI 2.2-5.3, P<0.001) and those with infection attributed to male-to-male sexual contact (EAPC=2.4, 95% CI 1.0-3.9, P=0.001) (Table 2). Black females showed no significant improvements in linkage to care from 2012-2015 with the exception of those with HIV-infection diagnosed without stage 3 [AIDS] (P=0.045). Similarly, linkage to care among Hispanic/Latino males aged 13-24 years (EAPC=3.2, 95% CI 0.3-6.2, P=0.033) and those with HIV infection without a diagnosis of stage 3 [AIDS] (EAPC=2.1, 95% CI 0.5-3.8, P=0.010) increased. There were no significant increases in linkage to care from 2012-2015 among Hispanic/Latino females or white males or females.

Table 2. Linkage to care among persons aged ≥13 years with HIV diagnosed during 2012-2015, by race, sex and selected characteristics – 17 US jurisdictionsa.
Characteristic Total Linked to careb for persons diagnosed in the year Trends from 2012 - 2015
2012 2013 2014 2015 EAPC 95% CI P-value
(N=20,876) (N=19,887) (N=20,467) (N=19,944)
No. (%) No. (%) No. (%) No. (%) Lower Upper
Black Males                          
      Age group at diagnosis                          
      13-24 8,002 1,442 70.5 1,482 74.7 1,541 75.0 1,511 78.8 3.4 1.1 5.8 0.004
      25-34 7,513 1,242 73.5 1,356 75.4 1,591 80.4 1,594 77.9 2.3 0.0 4.7 0.054
      35-44 3,612 747 75.9 705 78.4 721 82.2 683 80.2 2.2 -1.1 5.5 0.198
      45-54 3,090 692 76.8 631 79.4 571 82 569 81.5 2.2 -1.3 5.8 0.227
      55+ 1,890 384 79.7 374 78.2 404 82.6 364 82.5 1.6 -2.9 6.3 0.485
      Stage at diagnosis                          
      HIV infection stage 3(AIDS) 4,808 1,304 98.4 1,171 99.3 1,208 99.5 1,085 99.5 0.4 -2.1 3.0 0.774
      Not known to be HIV infection stage 3 19,299 3,203 67.1 3,377 70.7 3,620 74.1 3,636 74.8 3.8 2.2 5.3 <.001
      Transmission Categoryc                          
      Male-to-male sexual contact 19,012 3,463 73.9 3,562 76.7 3,876 79.1 3,790 79.3 2.4 1.0 3.9 0.001
      Injection drug use 1,212 284 75.2 216 72.2 204 76.6 202 75.4 0.6 -5 6.5 0.841
      Male-to-male sexual contact and injection drug use 603 102 69.0 116 67.3 124 79.5 95 75.6 4.8 -3.9 14.3 0.292
      Heterosexual contactd 3,229 647 74.1 644 77.9 615 81.0 625 81.1 3.1 -0.4 6.8 0.08
      Othere 51 11 65.6 10 89.2 9 72.5 8 72.2 1.6 -23 34.1 0.911
      Subtotal 24,107 4,507 73.9 4,548 76.4 4,828 79.2 4,721 79.3 2.5 1.2 3.8 <.001
Black Females                          
      Age group at diagnosis                          
      13-24 1,479 311 76.4 307 80.4 279 79.9 286 83.9 2.8 -2.3 8.1 0.289
      25-34 2,364 512 80.8 470 82.6 493 84 480 83.6 1.2 -2.7 5.3 0.541
      35-44 2,111 448 79.3 441 83.8 455 84.1 400 83.5 1.7 -2.5 6.0 0.446
      45-54 1,827 458 84.0 384 84.2 357 85.0 355 87.4 1.3 -3.1 5.8 0.6
      55+ 1,228 263 81.9 248 82.9 274 89.0 264 88.0 2.9 -2.5 8.6 0.302
      Stage at diagnosis                          
      HIV infection stage 3(AIDS) 2,092 573 99.1 501 98.8 529 99.2 472 99.6 0.2 -3.6 4.1 0.932
      Not known to be HIV infection stage 3 6,917 1,419 74.9 1,349 78.2 1,329 79.5 1,313 80.8 2.5 0.1 4.9 0.045
      Transmission Categoryc                          
      Injection drug use 948 236 76.8 184 80.0 165 78.3 161 80.2 1.2 -5.0 7.8 0.715
      Heterosexual contactd 8,017 1,746 81.1 1,653 83.2 1,689 85 1,615 85.5 1.8 -0.3 4 0.097
      Othere 43 10 89.4 13 88.6 4 54.2 9 93.1 -2.1 -27.1 31.4 0.887
      Subtotal 9,009 1,992 80.6 1,850 82.9 1,858 84.3 1,785 85.0 1.8 -0.2 3.9 0.083
Hispanic/Latino Males                          
      Age group at diagnosis                          
      13-24 4,586 864 75.0 848 79.8 940 79.5 992 83.4 3.2 0.3 6.2 0.033
      25-34 7,532 1,507 80.1 1,497 80.5 1,568 81.9 1,555 82.8 1.2 -1.1 3.5 0.301
      35-44 4,334 860 80.2 879 86.0 942 82.8 930 84.3 1.1 -1.8 4.1 0.459
      45-54 2,519 550 84.6 512 85.3 529 85.6 547 84.0 -0.2 -3.8 3.6 0.925
      55+ 996 217 87.1 203 85.3 208 86.7 227 84.4 -0.8 -6.5 5.2 0.784
      Stage at diagnosis                          
      HIV infection stage 3(AIDS) 4,667 1,201 98.4 1,171 99.0 1,129 98.8 1,110 99.0 0.2 -2.4 2.8 0.906
      Not known to be HIV infection stage 3 15,300 2,797 73.9 2,768 76.9 3,058 77.5 3,141 79.1 2.1 0.5 3.8 0.01
      Transmission Categoryc                          
      Male-to-male sexual contact 17,246 3,398 79.5 3,348 82.1 3,644 82.1 3,721 83.4 1.4 0.0 2.9 0.056
      Injection drug use 782 175 77.7 153 81.3 145 81.0 145 76.6 -0.3 -7.0 6.8 0.924
Male-to-male sexual contact and injection drug use 743 178 83.7 144 79.2 145 81.6 145 84.5 0.4 -6.4 7.7 0.903
      Heterosexual contactd 1,175 244 84.3 290 88.2 250 85.5 235 88.8 1.2 -4.3 7.1 0.671
      Othere 21 3 63.0 4 84.8 4 83.0 5 91.4 11.2 -27.0 69.1 0.622
      Subtotal 19,967 3,998 79.9 3,939 82.4 4,187 82.2 4,251 83.5 1.3 -0.1 2.7 0.059
Hispanic/Latino Females                          
      Age group at diagnosis                          
      13-24 465 88 75.2 86 81.1 111 83.5 87 79.8 2.2 -6.8 12.0 0.646
      25-34 729 147 76.6 134 78.4 149 77.6 136 78.2 0.5 -6.6 8.2 0.886
      35-44 674 149 87.1 147 86.0 153 86.4 133 85.8 -0.4 -7.5 7.2 0.914
      45-54 550 115 85.8 129 87.8 112 82.4 120 90.2 0.9 -7.0 9.4 0.834
      55+ 366 80 84.2 76 88.4 95 95.0 75 88.2 2.3 -7.2 12.8 0.649
      Stage at diagnosis                          
      HIV infection stage 3(AIDS) 699 175 97.8 174 98.3 177 98.9 164 100.0 0.7 -5.8 7.7 0.831
      Not known to be HIV infection stage 3 2,085 404 76.2 398 79.0 443 79.2 387 78.7 1 -3.3 5.5 0.654
      Transmission Categoryc                          
      Injection drug use 370 69 74.8 74 74.8 77 80.1 66 79.7 2.7 -7.7 14.2 0.623
      Heterosexual contactd 2,408 508 82.7 497 85.5 542 84.6 484 84.7 0.6 -3.3 4.6 0.762
      Othere 7 2 85.0 2 90.0 1 100.0 1 63.6 -4.3 -56.2 109.3 0.912
      Subtotal 2,784 579 81.7 572 84.0 620 84.0 551 84.0 0.9 -2.8 4.6 0.646
White Males                          
      Age group at diagnosis                          
      13-24 2,444 483 81.6 494 84.2 548 83.3 538 88.6 2.4 -1.5 6.5 0.23
      25-34 5,364 1,134 84.6 1,060 84.6 1,132 84.1 1,222 85.8 0.4 -2.2 3.0 0.789
      35-44 3,896 916 85.1 831 86.6 859 87.7 799 90.8 2.1 -1.0 5.2 0.184
      45-54 3,832 977 89.7 834 87.9 823 88.8 778 89.7 0.1 -2.9 3.1 0.972
      55+ 2,073 448 90.0 505 86.9 461 89.7 432 90.0 0.4 -3.7 4.6 0.867
      Stage at diagnosis                          
      HIV infection stage 3(AIDS) 4,008 1,046 98.8 1,020 98.5 961 98.9 934 99.3 0.2 -2.6 3.0 0.898
      Not known to be HIV infection stage 3 13,601 2,912 82.4 2,704 82.1 2,862 82.9 2,835 85.4 1.2 -0.5 2.9 0.156
      Transmission Categoryc                          
      Male-to-male sexual contact 15,056 3,428 86.3 3,197 86.2 3,305 86.7 3,159 88.6 0.8 -0.7 2.4 0.281
      Injection drug use 775 119 83.0 134 80.4 157 83.5 231 83.5 0.6 -6.1 7.8 0.859
      Male-to-male sexual contact and injection drug use 1,109 262 85.4 244 87.9 224 84.7 230 88.3 0.6 -4.9 6.4 0.828
      Heterosexual contactd 639 140 85.8 143 85.0 133 86.2 144 94.7 3.2 -4.2 11.2 0.406
      Othere 30 9 93.8 6 79.0 4 58.6 5 96.1 -4.6 -34.0 37.8 0.802
      Subtotal 17,609 3,958 86.1 3,724 86 3,823 86.4 3,769 88.5 0.8 -0.6 2.3 0.242
White Females                          
      Age group at diagnosis                          
      13-24 277 62 77.5 42 73.7 64 86.5 60 90.9 6.4 -5.1 19.2 0.289
      25-34 623 123 81.5 108 84.4 134 81.7 145 80.6 -0.7 -7.9 7.2 0.866
      35-44 555 110 79.1 113 81.3 102 81.6 125 82.2 1.2 -6.7 9.7 0.776
      45-54 473 92 88.5 99 86.8 108 90.0 118 87.4 0 -8.3 8.9 0.995
      55+ 288 63 87.5 68 84.0 54 90.0 63 84.0 -0.6 -11.0 11.0 0.918
      Stage at diagnosis                          
      HIV infection stage 3(AIDS) 509 156 98.7 121 98.4 112 100.0 116 100.0 0.5 -6.9 8.5 0.893
      Not known to be HIV infection stage 3 1,707 294 75.8 309 78.0 350 81.2 395 80.3 2.1 -2.7 7 0.398
      Transmission Categoryc                          
      Injection drug use 644 109 77.4 114 79.0 102 80.9 187 80.7 1.4 -5.9 9.2 0.715
      Heterosexual contactd 1,560 338 84.2 315 84.6 358 86.4 322 86.2 0.9 -3.8 5.9 0.704
      Othere 12 3 79.5 1 46.2 2 75.0 2 66.7 -3.2 -47.5 78.6 0.918
      Subtotal 2,216 450 82.4 430 82.9 462 85.1 511 84.0 0.8 -3.1 5.0 0.687
Total 81,174 16,670 79.9 16,197 81.4 16,959 82.9 16,695 83.7 1.6 0.9 2.3 <.001
Abbreviations: HIV= Human Immunodeficiency Virus, EAPC=Estimated Annual Percent. Note: The denominator for each characteristic for each year are not presented. aJurisdictions include California, District of Columbia, Hawaii, Iowa, Illinois, Indiana, Louisiana, Maryland, Michigan, Missouri, New Hampshire, New York, North Dakota, South Carolina, Texas, Utah, and West Virginia. bDefined as one or more CD4+ T-lymphocyte or viral load test within 1 month after HIV diagnosis. cData statistically adjusted to account for missing transmission categories. dHeterosexual contact with a person known to have, or to be at high risk for, HIV infection. eIncludes hemophilia, blood transfusion, perinatal exposure and risk factor not reported or not identified.

Overall, the proportion of people with diagnosed HIV infection who received care increased from 2012 to 2015 (EAPC=0.6, 95% CI 0.4-0.8, P<0.001) (Table 3). Receipt of care increased significantly for all individual categories of person characteristics assessed from 2012 to 2015, with the exception of those identifying as other race/ethnicity and other transmission category, those aged 45-54 years, and people who inject drugs. In each of the four years, the proportion of people who received care was consistently higher among whites and those classified as other race/ethnicity compared to blacks and Hispanics/Latinos and consistently lowest among those with a transmission category of injection drug use. There was little variation among age groups within years.

Table 3. Receipt of care among persons aged ≥13 years living with HIV, 17 US jurisdictionsa, 2012-2015.
Characteristic Receipt of Careb
2012 2013 2014 2015 Trend in 2012-2015
(N=440,375) (N=451,885) (N=464,461) (N=477,928) EAPC 95% CI P-value
No. (%) No. (%) No. (%) No. (%) Lower Upper
Sex
      Male 240,338 70.8 250,253 71.6 261,047 72.5 267,644 72.1 0.7 0.5 0.8 <.001
      Female 72,100 71.5 73,956 72.2 75,582 72.4 77,191 72.4 0.4 0.1 0.7 .011
Race/Ethnicity
      Black/African American 117,215 68.2 122,090 69.4 126,963 69.9 130,784 69.8 0.8 0.5 1.1 <.001
      Hispanic/Latino 75,236 68.9 78,513 69.3 82,354 70.2 85,046 69.8 0.5 0.2 0.8 <.001
      White 98,207 74.7 101,076 75.3 103,959 76.4 105,162 75.7 0.5 0.3 0.8 <.001
      Other 21,780 78.8 22,530 79.4 23,353 79.7 23,843 79.4 0.3 -0.3 0.8 .379
Age group at diagnosis
      13-24 10,941 70.2 11,546 72.5 11,819 74.5 11,753 75.2 2.4 1.5 3.2 <.001
      25-34 42,941 68.9 45,144 70.4 48,086 71.8 50,639 72.5 1.7 1.3 2.1 <.001
      35-44 76,771 70.2 74,827 71.0 73,406 71.6 71,621 71.4 0.6 0.3 0.9 <.001
      45-54 114,184 72.7 116,821 73.3 118,737 73.8 118,052 73.2 0.2 0 0.5 .058
      55+ 67,601 70.3 75,871 70.8 84,581 71.5 92,770 71.0 0.3 0 0.6 .039
Stage at diagnosis
      HIV infection stage 3(AIDS) 77,369 70.8 79,592 71.5 81,523 72.0 82,732 71.7 0.4 0.1 0.7 .006
      Not known to be HIV infection stage 3 235,069 71.0 244,617 71.8 255,106 72.6 262,103 72.3 0.6 0.5 0.8 <.001
Transmission Categoryc
      Male-to-male sexual contact 172,781 72.7 181,665 73.4 191,919 74.4 198,957 73.9 0.6 0.4 0.8 <.001
      Injection drug use 44,880 63.9 44,843 64.6 44,350 64.6 43,421 63.9 0 -0.4 0.4 .926
      Male-to-male sexual contact and injection drug use 21,469 75.3 21,684 76.5 21,828 77.2 21,607 76.6 0.6 0 1.2 .037
      Heterosexual contactd 72,026 70.6 74,735 71.4 77,251 71.7 79,574 71.8 0.5 0.2 0.8 .001
      Othere 1,282 68.8 1,283 69.4 1,281 69.8 1,276 69.0 0.1 -2.3 2.6 .912
Total 312,438 70.9 324,209 71.7 336,629 72.5 344,835 72.2 0.6 0.4 0.8 <.001
Abbreviations: HIV= Human Immunodeficiency Virus, EAPC=Estimated Annual Percent Change.
Note: The denominator for each characteristic for each year are not presented. aJurisdictions include California, District of Columbia, Hawaii, Iowa, Illinois, Indiana, Louisiana, Maryland, Michigan, Missouri, New Hampshire, New York, North Dakota, South Carolina, Texas, Utah, and West Virginia. bDefined as one or more CD4+ T-lymphocyte or viral load test performed during the outcome year. cData statistically adjusted to account for missing transmission categories. dHeterosexual contact with a person known to have, or to be at high risk for, HIV infection. eIncludes hemophilia, blood transfusion, perinatal exposure and risk factor not reported or not identified.

By race/ethnicity and sex, significant increases in the proportion of those who received care annually from 2012-2015 were found among black males of all ages except ≤55 years, Hispanic/Latino males aged 13-24 and 25-34 years, and all racial/ethnic groups diagnosed without Stage 3 [AIDS] except Hispanic/Latino and white females (Table 4). Receipt of care increased from 2012-2015 among all racial/ethnic groups of men who have male to male sexual contact (blacks EAPC=1.0, 95% CI 0.6-1.4, P<.001; Hispanics/Latinos EAPC=0.8, 95% CI 0.4-1.2, P<.001; whites EAPC=0.5, 95% CI 0.1-0.8, P=.004). Receipt of care also increased among black females aged 35-44 years (EAPC=1.0, 95% CI 0.2-1.8, P=.020) and transmission category of heterosexual contact (EAPC=0.7, 95% CI 0.2-1.2, P=.008).

Viral suppression among people with diagnosed HIV infection increased annually from 2012 to 2015 overall (53.4%, 56.4%, 58.8%, and 59.2% respectively) (EAPC=3.5, 95% CI 3.3-3.7, P<.001) (Table 5) and for all categories of person characteristics assessed. Within years, the proportion of people achieving viral suppression was consistently greater among males, whites, and people with HIV infection Stage 3 [AIDS], and consistently lowest among those with a transmission category of injection drug use. The proportion of those achieving viral suppression increased with age each year.

Table 4. Receipt of care among persons aged ≥13 years living with HIV in 17 US jurisdictionsa by race, sex and selected characteristics, 2012-2015
Characteristic Receipt of Careb
2012 2013 2014 2015 Trend in 2012-2015
(N=440,375) (N=451,885) (N=464,461) (N=477,928) EAPC 95% CI P-value
No. (%) No. (%) No. (%) No. (%) Lower Upper
Black Male
      Age group at diagnosis
      13-24 4,694 68.3 5,059 70.8 5,269 73.0 5,216 73.4 2.5 1.2 3.7 <.001
      25-34 12,119 66.5 13,252 68.5 14,932 70.4 16,586 71.3 2.3 1.6 3.1 <.001
      35-44 16,430 66.9 16,071 68.4 15,972 69.4 15,772 69.5 1.3 0.6 2.0 <.001
      45-54 26,489 68.4 27,001 70.0 27,228 70.3 26,736 69.8 0.6 0.1 1.2 .018
      55+ 16,234 64.6 18,275 65.2 20,111 65.3 21,898 64.8 0.1 -0.6 0.7 .832
      Stage at diagnosis
      HIV infection stage 3(AIDS) 19,669 69.2 20,250 70.4 20,732 70.8 20,973 70.3 0.5 -0.1 1.1 .101
      Not known to be HIV infection stage 3 56,297 66.2 59,408 67.6 62,780 68.5 65,235 68.4 1.1 0.8 1.5 <.001
      Transmission Categoryc
      Male-to-male sexual contact 45,019 69.0 48,073 70.2 51,704 71.1 54,684 71.1 1.0 0.6 1.4 <.001
      Injection drug use 12,834 59.5 13,004 61.3 12,738 61.0 12,319 59.9 0.2 -0.6 1.0 .650
      Male-to-male sexual contact and injection drug use 6,359 71.8 6,407 73.8 6,462 74.8 6,332 73.5 0.8 -0.3 1.9 .135
      Heterosexual contactd 11,570 66.1 11,987 67.0 12,413 67.5 12,680 67.4 0.7 -0.1 1.5 .108
      Othere 184 63.2 187 63.2 195 64.5 193 62.2 -0.3 -6.4 6.3 .930
Black Female
      Age group at diagnosis
      13-24 1,477 69.8 1,412 72.3 1,341 71.7 1,266 74.3 1.8 -0.6 4.3 .133
      25-34 6,182 66.8 6,012 67.6 5,845 67.8 5,804 68.7 0.9 -0.2 2.0 .127
      35-44 11,461 68.2 11,460 69.3 11,365 69.9 11,319 70.3 1.0 0.2 1.8 .020
      45-54 13,997 73.3 14,297 73.5 14,582 73.4 14,736 73.0 -0.1 -0.8 0.6 .774
      55+ 8,132 72.8 9,251 73.4 10,318 73.5 11,451 73.2 0.2 -0.7 1.0 .738
      Stage at diagnosis
      HIV infection stage 3(AIDS) 9,540 73.4 9,758 74.0 9,948 74.3 10,141 74.1 0.3 -0.5 1.2 .459
      Not known to be HIV infection stage 3 31,709 69.8 32,674 70.6 33,503 70.9 34,435 71.1 0.6 0.1 1.1 .012
      Transmission Categoryc
      Injection drug use 10,264 69.1 10,221 69.9 10,102 69.9 9,931 69.3 0.1 -0.8 1.0 .832
      Heterosexual contactd 30,771 71.1 31,982 71.8 33,119 72.1 34,414 72.5 0.7 0.2 1.2 .008
      Othere 214 71.8 230 75.3 230 74.0 231 73.0 0.3 -5.4 6.3 .918
Hispanic/Latino Male
      Age group at diagnosis
      13-24 2,183 70.8 2,422 73.6 2,571 77.7 2,676 77.8 3.3 1.5 5.2 <.001
      25-34 10,254 67.6 10,952 68.9 11,973 71.5 12,631 72.5 2.5 1.7 3.3 <.001
      35-44 17,365 67.8 17,085 67.9 17,026 68.7 16,973 68.6 0.5 -0.2 1.1 .167
      45-54 19,947 69.0 21,062 69.5 22,025 69.7 22,554 69.1 0.0 -0.6 0.6 .879
      55+ 9,694 65.0 10,874 65.0 12,219 65.5 13,500 65.0 0.1 -0.8 0.9 .892
      Stage at diagnosis
      HIV infection stage 3(AIDS) 16,836 64.6 17,505 65.2 18,097 65.6 18,544 65.5 0.5 -0.2 1.2 .142
      Not known to be HIV infection stage 3 42,607 69.2 44,890 69.5 47,717 70.7 49,790 70.4 0.7 0.3 1.1 .001
      Transmission Categoryc
      Male-to-male sexual contact 42,691 69.9 45,560 70.5 48,849 71.7 51,470 71.5 0.8 0.4 1.2 <.001
      Injection drug use 7,210 56.4 7,068 55.7 7,026 55.7 6,861 54.8 -0.9 -1.9 0.2 .106
      Male-to-male sexual contact and injection drug use 4,915 73.1 5,004 74.0 4,999 73.8 4,975 73.3 0.0 -1.2 1.3 .971
      Heterosexual contactd 4,495 64.8 4,627 65.1 4,806 65.5 4,900 64.9 0.1 -1.2 1.4 .876
      Othere 133 63.4 136 64.4 134 64.4 127 61.9 -0.7 -8.0 7.2 .863
Hispanic/Latino Female
      Age group at diagnosis
      13-24 406 70.2 381 70.4 372 74.3 348 73.4 1.9 -2.6 6.6 .417
      25-34 2,139 69.4 2,065 70.2 1,978 70.2 1,923 70.0 0.3 -1.7 2.2 .791
      35-44 4,262 71.9 4,228 72.5 4,177 73.3 3,993 72.4 0.4 -1.0 1.7 .611
      45-54 5,553 75.5 5,640 75.5 5,771 76.0 5,759 75.5 0.1 -1.1 1.3 .875
      55+ 3,433 74.5 3,804 74.2 4,242 74.6 4,689 73.6 -0.4 -1.7 1.0 .612
      Stage at diagnosis
      HIV infection stage 3(AIDS) 3,760 72.3 3,799 72.2 3,882 72.7 3,932 72.1 0.0 -1.4 1.4 .980
      Not known to be HIV infection stage 3 12,033 73.6 12,319 74.0 12,658 74.7 12,780 74.0 0.2 -0.5 1.0 .549
      Transmission Categoryc
      Injection drug use 4,256 71.8 4,211 71.8 4,170 71.7 4,107 71.1 -0.3 -1.6 1.1 .689
      Heterosexual contactd 11,440 73.9 11,810 74.2 12,274 75.1 12,511 74.4 0.3 -0.5 1.1 .445
      Othere 97 70.3 97 71.6 95 70.3 94 68.3 -1.0 -9.5 8.2 .819
White Male
      Age group at diagnosis
      13-24 1,181 74.3 1,215 75.5 1,246 76.4 1,292 77.6 1.5 -1.0 4.0 .258
      25-34 7,593 74.6 8,077 76.3 8,378 76.9 8,602 76.4 0.8 -0.2 1.8 .117
      35-44 18,741 75.1 17,634 75.8 16,721 76.6 15,606 75.7 0.4 -0.3 1.1 .267
      45-54 36,888 76.3 37,190 76.7 37,270 77.7 36,283 76.8 0.4 -0.1 0.8 .127
      55+ 23,565 74.2 26,448 75.0 29,709 76.7 32,516 76.1 0.9 0.4 1.5 <.001
      Stage at diagnosis
      HIV infection stage 3(AIDS) 20,210 74.4 20,660 74.9 21,108 75.9 21,276 75.6 0.6 0.0 1.2 .053
      Not known to be HIV infection stage 3 67,758 75.6 69,904 76.3 72,216 77.5 73,023 76.6 0.6 0.2 0.9 .001
      Transmission Categoryc
      Male-to-male sexual contact 73,065 76.0 75,358 76.6 77,922 77.8 78,872 76.9 0.5 0.1 0.8 .004
      Injection drug use 3,936 62.2 4,012 63.6 4,036 64.5 4,004 63.9 1.0 -0.4 2.4 .171
      Male-to-male sexual contact and injection drug use 8,210 77.4 8,318 78.3 8,428 79.7 8,406 79.6 1.0 0.0 2.0 .041
      Heterosexual contactd 2,346 71.6 2,483 73.6 2,557 73.6 2,633 74.2 1.1 -0.7 2.9 .234
      Othere 410 73.9 392 72.7 381 73.3 384 74.0 0.1 -4.2 4.6 .968
White Female
      Age group at diagnosis
      13-24 259 69.4 243 69.2 204 68.7 182 65.9 -1.5 -7.2 4.5 .610
      25-34 1,365 67.6 1,340 68.3 1,294 68.1 1,275 68.8 0.5 -1.9 2.9 .701
      35-44 2,681 68.1 2,639 69.5 2,521 69.2 2,448 69.2 0.4 -1.3 2.2 .643
      45-54 3,690 70.5 3,790 71.2 3,843 71.0 3,864 71.5 0.4 -1.0 1.8 .607
      55+ 2,244 71.5 2,500 71.7 2,773 71.7 3,094 71.7 0.1 -1.6 1.8 .936
      Stage at diagnosis
      HIV infection stage 3(AIDS) 2,221 71.5 2,313 73.1 2,336 72.5 2,369 73.0 0.5 -1.3 2.4 .573
      Not known to be HIV infection stage 3 8,018 69.2 8,199 69.7 8,299 69.7 8,494 69.9 0.3 -0.6 1.3 .512
      Transmission Categoryc
      Injection drug use 3,306 65.9 3,332 66.6 3,342 66.9 3,337 66.9 0.5 -1.1 2.0 .560
      Heterosexual contactd 6,789 71.7 7,040 72.5 7,155 72.1 7,384 72.4 0.2 -0.8 1.3 .653
      Othere 145 66.5 139 65.8 138 66.8 142 68.9 1.2 -6.0 8.9 .748
Total 312,438 70.9 324,209 71.7 336,629 72.5 344,835 72.2 0.6 0.4 0.8 <.001
Abbreviations: HIV= Human Immunodeficiency Virus, EAPC=Estimated Annual Percent Change. Note: The denominator for each characteristic for each year are not presented. aJurisdictions include California, District of Columbia, Hawaii, Iowa, Illinois, Indiana, Louisiana, Maryland, Michigan, Missouri, New Hampshire, New York, North Dakota, South Carolina, Texas, Utah, and West Virginia. bDefined as one or more CD4+ T-lymphocyte or viral load test performed during the outcome year. cData statistically adjusted to account for missing transmission categories. dHeterosexual contact with a person known to have, or to be at high risk for, HIV infection. eIncludes hemophilia, blood transfusion, perinatal exposure and risk factor not reported or not identified.
Table 5. Viral suppression among persons aged ≥13 years living with HIV, 17 US jurisdictionsa, 2012-2015
Characteristic Viral Suppression
2012 2013 2014 2015 Trend in 2012-2015
(N=440,375) (N=451,885) (N=464,461) (N=477,928) EAPC 95% CI P-value
No. (%) No. (%) No. (%) No. (%) Lower Upper
Sex
      Male 184,330 54.3 199,908 57.2 214,601 59.6 221,923 59.8 3.3 3.1 3.5 <.001
      Female 50,921 50.5 54,913 53.6 58,458 56.0 60,886 57.1 4.2 3.8 4.6 <.001
Race/Ethnicity
      Black/Afican American 80,058 46.6 87,808 49.9 94,951 52.3 99,078 52.9 4.3 4 4.6 <.001
      Hispanic/Latino 58,732 53.8 63,416 56.0 68,760 58.6 71,787 59.0 3.2 2.9 3.6 <.001
      White 80,078 60.9 85,921 64.1 90,356 66.4 92,223 66.4 3 2.7 3.3 <.001
      Other 16,383 59.3 17,676 62.3 18,992 64.8 19,721 65.7 3.5 2.8 4.2 <.001
Age group at diagnosis
      13-24 6,201 39.8 7,200 45.2 7,911 49.9 8,246 52.8 9.8 8.6 10.9 <.001
      25-34 28,504 45.8 32,115 50.1 35,666 53.3 38,058 54.5 5.9 5.4 6.4 <.001
      35-44 56,423 51.6 57,282 54.3 58,184 56.8 57,243 57.1 3.5 3.1 3.9 <.001
      45-54 88,692 56.5 94,059 59.0 98,182 61.0 98,479 61.0 2.7 2.4 3 <.001
      55+ 55,431 57.7 64,165 59.9 73,116 61.8 80,783 61.8 2.3 2 2.7 <.001
Stage at diagnosis
      HIV infection stage 3(AIDS) 61,281 56.1 65,045 58.4 68,374 60.4 69,991 60.6 2.7 2.3 3 <.001
      Not known to be HIV infection stage 3 173,970 52.5 189,776 55.7 204,685 58.3 212,818 58.7 3.8 3.6 4 <.001
Transmission Categoryc
      Male-to-male sexual contact 135,257 56.9 148,554 60.0 160,922 62.4 168,400 62.6 3.2 3 3.5 <.001
      Injection drug use 31,578 44.9 32,747 47.2 33,706 49.1 33,182 48.8 2.9 2.4 3.4 <.001
      Male-to-male sexual contact and injection drug use 15,331 53.7 16,017 56.5 16,769 59.3 16,652 59.0 3.3 2.6 4.1 <.001
      Heterosexual contactd 52,111 51.1 56,492 54.0 60,613 56.3 63,499 57.3 3.9 3.5 4.2 <.001
      Othere 974 52.3 1,011 54.7 1,050 57.2 1,076 58.2 3.7 0.9 6.6 .009
Total 235,251 53.4 254,821 56.4 273,059 58.8 282,809 59.2 3.5 3.3 3.7 <.001
Abbreviations: HIV= Human Immunodeficiency Virus, EAPC=Estimated Annual Percent Change. Note: The denominator for each characteristic for each year are not presented. aJurisdictions include California, District of Columbia, Hawaii, Iowa, Illinois, Indiana, Louisiana, Maryland, Michigan, Missouri, New Hampshire, New York, North Dakota, South Carolina, Texas, Utah, and West Virginia. bDefined as a viral load result of <200 copies/mL or, if the quantitative value was missing, a test interpretation value of “undetected”, at the time of the most recent viral load test during the outcome year. cData statistically adjusted to account for missing transmission categories. dHeterosexual contact with a person known to have, or to be at high risk for, HIV infection. eIncludes hemophilia, blood transfusion, perinatal exposure and risk factor not reported or not identified.

By race/ethnicity and sex, viral suppression increased annually from 2012-2015 for all characteristics except transmission category of other for all racial/ethnic groups, and Hispanic/Latino and white females aged 13-24 years (Table 6).

Table 6. Viral suppression among persons aged ≥13 years living with HIV in 17 US jurisdictions by race, sex and selected characteristics, 2012-2015
Characteristic Viral Suppression
2012 2013 2014 2015 Trend in 2012-2015
(N=440,375) (N=451,885) (N=464,461) (N=477,928) EAPC 95% CI P-value
No. (%) No. (%) No. (%) No. (%) Lower Upper
Black Male
      Age group at diagnosis
      13-24 2,513 36.6 2,967 41.5 3,348 46.4 3,436 48.3 9.8 8.0 11.5 <.001
      25-34 7,340 40.3 8,697 44.9 10,253 48.3 11,560 49.7 7.0 6.0 8.0 <.001
      35-44 11,105 45.2 11,413 48.6 11,852 51.5 11,666 51.4 4.5 3.7 5.4 <.001
      45-54 18,904 48.8 20,028 51.9 20,868 53.9 20,553 53.7 3.2 2.6 3.9 <.001
      55+ 12,388 49.3 14,368 51.3 16,204 52.6 17,856 52.8 2.3 1.5 3.0 <.001
      Stage at diagnosis
      HIV infection stage 3(AIDS) 14,476 51.0 15,418 53.6 16,244 55.4 16,603 55.7 3.0 2.3 3.7 <.001
      Not known to be HIV infection stage 3 37,774 44.4 42,055 47.9 46,281 50.5 48,468 50.8 4.6 4.1 5.0 <.001
      Transmission Categoryc
      Male-to-male sexual contact 30,899 47.3 34,892 50.9 38,904 53.5 41,682 54.2 4.5 4.1 5.0 <.001
      Injection drug use 8,850 41.0 9,267 43.7 9,451 45.2 9,040 44.0 2.5 1.5 3.4 <.001
      Male-to-male sexual contact and injection drug use 4,202 47.4 4,394 50.6 4,651 53.8 4,513 52.4 3.6 2.3 5.0 <.001
      Heterosexual contactd 8,182 46.8 8,800 49.2 9,379 51.0 9,699 51.6 3.3 2.4 4.3 <.001
      Othere 117 40.2 120 40.6 140 46.3 137 44.3 4.3 -3.5 12.7 .288
Black Female
      Age group at diagnosis
      13-24 683 32.3 741 37.9 758 40.6 778 45.7 11.7 8.1 15.4 <.001
      25-34 3,544 38.3 3,727 41.9 3,780 43.8 3,901 46.2 6.2 4.7 7.8 <.001
      35-44 7,537 44.9 7,909 47.8 8,228 50.6 8,352 51.8 5.0 4.0 6.0 <.001
      45-54 9,887 51.7 10,560 54.3 11,190 56.3 11,487 56.9 3.2 2.4 4.1 <.001
      55+ 6,157 55.1 7,398 58.7 8,470 60.3 9,489 60.6 3.0 2.0 4.1 <.001
      Stage at diagnosis
      HIV infection stage 3(AIDS) 6,984 53.7 7,471 56.7 7,823 58.4 8,140 59.5 3.4 2.4 4.4 <.001
      Not known to be HIV infection stage 3 20,824 45.8 22,864 49.4 24,603 52.0 25,867 53.4 5.2 4.6 5.8 <.001
      Transmission Categoryc
      Injection drug use 6,693 45.1 7,062 48.3 7,318 50.6 7,323 51.1 4.3 3.2 5.4 <.001
      Heterosexual contactd 20,969 48.4 23,108 51.9 24,930 54.3 26,503 55.9 4.8 4.2 5.4 <.001
      Othere 146 49.1 166 54.2 178 57.3 182 57.4 5.2 -1.7 12.6 .140
Hispanic/Latino Male
      Age group at diagnosis
      13-24 1,389 45.1 1,677 51.0 1,904 57.5 2,044 59.4 9.7 7.4 12.0 .001
      25-34 7,437 49.0 8,360 52.6 9,452 56.4 10,111 58.0 5.8 4.9 6.8 <.001
      35-44 13,552 52.9 13,819 54.9 14,225 57.4 14,231 57.5 3.0 2.2 3.7 <.001
      45-54 16,193 56.1 17,525 57.8 18,893 59.8 19,501 59.8 2.2 1.6 2.9 <.001
      55+ 8,258 55.4 9,455 56.5 10,909 58.5 12,037 57.9 1.6 0.8 2.5 <.001
      Stage at diagnosis
      HIV infection stage 3(AIDS) 13,921 53.4 14,727 54.9 15,701 57.0 16,111 56.9 2.3 1.6 3.0 <.001
      Not known to be HIV infection stage 3 32,908 53.4 36,109 55.9 39,682 58.8 41,813 59.1 3.5 3.1 4.0 <.001
      Transmission Categoryc
      Male-to-male sexual contact 34,225 56.1 37,902 58.6 41,716 61.2 44,306 61.6 3.2 2.8 3.7 <.001
      Injection drug use 5,439 42.6 5,462 43.1 5,662 44.9 5,526 44.1 1.5 0.3 2.7 .012
      Male-to-male sexual contact and injection drug use 3,520 52.4 3,667 54.2 3,854 56.9 3,835 56.5 2.8 1.3 4.2 <.001
      Heterosexual contactd 3,533 51.0 3,691 51.9 4,033 54.9 4,137 54.8 2.8 1.3 4.2 <.001
      Othere 112 53.6 115 54.4 119 57.3 120 58.3 3.1 -4.9 11.9 .460
Hispanic/Latino Female
      Age group at diagnosis
      13-24 246 42.6 239 44.2 243 48.5 234 49.4 5.5 -0.3 11.7 .061
      25-34 1,409 45.7 1,449 49.3 1,452 51.5 1,450 52.8 4.9 2.5 7.3 <.001
      35-44 3,117 52.6 3,153 54.0 3,248 57.0 3,197 58.0 3.5 1.9 5.2 <.001
      45-54 4,282 58.2 4,454 59.7 4,717 62.1 4,828 63.3 3.0 1.7 4.3 <.001
      55+ 2,849 61.9 3,285 64.1 3,717 65.4 4,154 65.2 1.7 0.2 3.2 .028
      Stage at diagnosis
      HIV infection stage 3(AIDS) 2,990 57.5 3,121 59.3 3,298 61.8 3,410 62.5 2.9 1.4 4.6 <.001
      Not known to be HIV infection stage 3 8,913 54.5 9,459 56.8 10,079 59.4 10,453 60.5 3.6 2.7 4.5 <.001
      Transmission Categoryc
      Injection drug use 3,037 51.2 3,099 52.9 3,194 54.9 3,260 56.5 3.4 1.8 5.0 <.001
      Heterosexual contactd 8,792 56.8 9,406 59.1 10,105 61.8 10,525 62.6 3.4 2.5 4.3 <.001
      Othere 74 53.8 75 55.2 78 57.6 78 56.9 2.1 -7.6 12.9 .679
White Male
      Age group at diagnosis
      13-24 803 50.5 931 57.8 966 59.3 1,060 63.7 7.3 4.3 10.4 <.001
      25-34 5,580 54.9 6,420 60.6 6,911 63.4 7,152 63.6 4.8 3.7 6.0 <.001
      35-44 14,844 59.5 14,568 62.6 14,139 64.8 13,338 64.7 2.9 2.2 3.7 <.001
      45-54 30,648 63.4 32,129 66.2 32,669 68.1 32,065 67.9 2.4 1.9 2.9 <.001
      55+ 20,434 64.3 23,543 66.8 26,875 69.4 29,606 69.3 2.5 2.0 3.1 <.001
      Stage at diagnosis
      HIV infection stage 3(AIDS) 17,032 62.7 18,019 65.3 18,688 67.2 18,950 67.3 2.4 1.7 3.1 <.001
      Not known to be HIV infection stage 3 55,277 61.6 59,572 65.0 62,872 67.4 64,271 67.4 3.0 2.7 3.4 <.001
      Transmission Categoryc
      Male-to-male sexual contact 60,780 63.3 65,462 66.5 68,995 68.9 70,553 68.8 2.8 2.5 3.2 <.001
      Injection drug use 3,024 47.8 3,171 50.3 3,252 52.0 3,210 51.3 2.5 0.9 4.1 .002
      Male-to-male sexual contact and injection drug use 6,244 58.9 6,541 61.6 6,810 64.4 6,877 65.1 3.5 2.4 4.6 <.001
      Heterosexual contactd 1,932 58.9 2,083 61.7 2,172 62.5 2,238 63.1 2.2 0.2 4.1 .028
      Othere 329 59.4 334 61.9 332 63.7 343 66.1 3.6 -1.3 8.6 .151
White Female
      Age group at diagnosis
      13-24 147 39.4 148 42.2 132 44.4 127 46.0 5.3 -2.2 13.5 .172
      25-34 907 44.9 921 47.0 965 50.8 926 49.9 4.0 1.1 7.1 .007
      35-44 1,925 48.9 1,978 52.1 1,952 53.6 1,907 53.9 3.2 1.2 5.3 .002
      45-54 2,926 55.9 3,116 58.5 3,265 60.3 3,274 60.6 2.7 1.1 4.3 <.001
      55+ 1,864 59.4 2,167 62.1 2,482 64.1 2,768 64.1 2.5 0.7 4.4 .007
      Stage at diagnosis
      HIV infection stage 3(AIDS) 1,786 57.5 1,914 60.5 2,017 62.6 2,047 63.1 3.1 1.1 5.2 .003
      Not known to be HIV infection stage 3 5,983 51.6 6,416 54.6 6,779 56.9 6,955 57.3 3.6 2.4 4.7 <.001
      Transmission Categoryc
      Injection drug use 2,359 47.1 2,518 50.4 2,625 52.5 2,620 52.5 3.7 1.9 5.6 <.001
      Heterosexual contactd 5,294 55.9 5,689 58.6 6,055 61.0 6,255 61.4 3.2 2.0 4.4 <.001
      Othere 116 53.4 123 58.0 116 56.2 127 61.6 4.1 -3.9 12.7 .327
Total 235,251 53.4 254,821 56.4 273,059 58.8 282,809 59.2 3.5 3.3 3.7 <.001
Abbreviations: HIV= Human Immunodeficiency Virus, EAPC=Estimated Annual Percent Change. Note: The denominator for each characteristic for each year are not presented. aJurisdictions include California, District of Columbia, Hawaii, Iowa, Illinois, Indiana, Louisiana, Maryland, Michigan, Missouri, New Hampshire, New York, North Dakota, South Carolina, Texas, Utah, and West Virginia. bDefined as a viral load result of <200 copies/mL or, if the quantitative value was missing, a test interpretation value of “undetected”, at the time of the most recent viral load test during the outcome year. cData statistically adjusted to account for missing transmission categories. dHeterosexual contact with a person known to have, or to be at high risk for, HIV infection. eIncludes hemophilia, blood transfusion, perinatal exposure and risk factor not reported or not identified.

4. DISCUSSION/IMPLICATIONS

This analysis explored progress in linkage to care, receipt of care, and viral suppression among people with HIV infection for outcome years 2012-2015 in 17 U.S. jurisdictions meeting the criteria for complete laboratory reporting for each of the four years. Linkage-to-care increases were found among some high-risk populations, particularly young people, blacks, males, and those engaging in male-to-male sexual contact. However, an increase was found in only one category of black women, those with a diagnosis of HIV Stage 3 [AIDS], despite black women being a priority population for HIV prevention. Notably, Hispanic/Latino and white females and white males showed no improvement in linkage to care from 2012-2015; however, the proportions at which they were linked to care were close to or higher than the national standard and exceeded linkage for black males by approximately five percentage points.

Generally, receipt of care improved among the same populations as linkage to care and also showed improvements for white men who have male to male sexual contact. Once again, no improvements were found among Hispanic/Latino or white women. Despite limited improvement in linkage to and receipt of care, and similar to another study [16], increases in viral suppression were seen in nearly every category of person characteristics assessed. This is potentially due to a number of factors including improvements in linkage to care and receipt of care that were found and increased prescribing of or compliance with antiretroviral therapy.

The distinction in linkage to and receipt of care and viral suppression between those with HIV diagnosed at stage 3 [AIDS] and not at stage 3 [AIDS] is prominent. Those with stage 3 [AIDS] are linked to care in greater proportions than those not in stage 3 [AIDS]. However, the differences between the two groups disappear for receipt of care. Then, once again, those with HIV diagnosed at Stage 3 [AIDS] achieve viral suppression more often than those not at stage 3 [AIDS]. These variations suggest the need to better understand why those with stage 3 [AIDS] are linked but did not receive care in any greater proportion than those not at stage 3 [AIDS].

A similar scenario is seen for linkage to and receipt of care and viral suppression by age group. While linkage to care and viral suppression both increase as age increases, this is not the case for receipt of care where the proportions vary within age categories. A better understanding of the impact of age on receipt of care could be important in increasing the proportion of those virally suppressed for all age groups.

Studies documenting the impact of poverty, poor education, substance use, mental health challenges, domestic violence, transportation to medical care, and lack of social support and employment on HIV care and treatment are abundant, and demonstrate disproportional impact on black men and women and Hispanics/Latinos, and on high-risk populations such as people who inject drugs and young men having sexual contact with men [7, 17-23]. Despite these barriers a number of evidence-based programs targeting these populations, including pre-exposure prophylaxis, demonstrate effective outcomes [24-26]. However, within years substantial differences remain in linkage to and receipt of care and viral suppression with whites exceeding blacks and Hispanics/Latinos, suggesting the effectiveness of programs to reduce the health disparities are limited [27].

The analysis was subject to several limitations. First, the outcomes assessed included only cases identified through 2015 and were under the guidance of the National HIV/AIDS Strategy for the United States: July 2010 [28]. The 2010 guidance established a linkage to care goal of 65% which was met for virtually every person characteristic group assessed and a retention in care goal of 80% for which our more liberal definition showed no person characteristic group met the goal. The 2010 guidance also set a goal of a 20% increase in the proportion of HIV diagnosed gay and bisexual men as well as Blacks with undetectable viral load which we cannot assess as we used 2012-2015 data. Improvements in testing and care and treatment since 2015 make it critical to continue to assess these outcomes under the new 2020 strategy released in July 2015. Second, the 17 jurisdictions may not be representative of all people with HIV infection in the United States. To mitigate the lack of representation we looked back no further than 2012. Including earlier years would have further reduced the number of states eligible for the analysis. Third, the EAPC for linkage to care is based on only four years of data due to the lack of complete laboratory reporting in other jurisdictions. Fourth, documentation of the most recent viral load may not be indicative of consistent viral suppression in this population over time [29] and further studies are needed to understand factors contributing to long term viral suppression. Fifth, exclusion of laboratory results with missing month or year of specimen collection date may underestimate linkage-to-care, receipt-of-care, and viral suppression. To address the majority of the limitation above, states continue to work with their legislatures to enact mandatory HIV-related laboratory test result reporting laws and all but six (Idaho, Kansas, New Jersey, Pennsylvania, Vermont, and the Virgin Islands) have now done so with the latest being Arizona in 2018. Opportunities to expand analyses will occur as states collect this data. Additional studies are needed as more jurisdictions begin to meet the laboratory reporting requirements.

CONCLUSION

Improving care and treatment for people with HIV infection and reducing HIV-related disparities across the three indicators studied show some promising results; however, linkage-to-care and viral suppression indicators fall short of National HIV/AIDS Strategy for the United States: Updated to 2020 goals. While not a national indicator, the more inclusive definition used in this study for receipt of care (one HIV-related medical visit per year) still falls short of the retention in care (two or more HIV-related medical visits more than three months apart in a year) national goal and thus there also remain opportunities for improvement in receipt of care.

Prevention programs that are scientifically proven, cost-effective, scalable and targeted to high-risk populations are the foundation for stopping transmission of HIV infection. Frequent testing to support early diagnosis and prompt linkage to medical care, particularly among young men who have male to male sexual contact and black and Hispanic/Latino populations, are key to reducing transmission at all stages of disease, and specifically among those with acute infection when transmission risk is high. The substantial disparity in receipt of care and viral suppression among racial/ethnic groups suggests the need for improved targeting of interventions based on social determinants of health. Resources are still needed to monitor and improve outcomes across the HIV continuum of care. The transition from the July 2010 national strategy to the 2020 updated national strategy presents an opportunity to reassess local, state, and national programs to reach these care continuum goals.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No Animals/Humans were used for studies that are base of this research.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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