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

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.


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), Receipt of care and viral load suppression analyses included people with HIV diagnosed before January 1 st of the outcome year and not known to be deceased on December 31 st 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.  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

Trends in HIV Infection Care and Treatment
The 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.   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. c Data statistically adjusted to account for missing transmission categories. d Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. e Includes 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).

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. 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