New HIV Diagnoses: Large Improvements In Some Groups Overshadow Results for People and Places Being Left Behind

New HIV diagnoses are on the decline in the United States. Our previous blog in the National HIV/AIDS Strategy (NHAS) Indicator series showed that from 2010 to 2014 there was nearly a 7% decline in new diagnoses. Further, in 2014, we met the annual NHAS target for reducing new HIV diagnoses overall.

Taking a deeper look, we see that the overall result is driven by larger than average improvement among people who inject drugs, heterosexuals, and Blacks/African Americans. The strong improvement in these groups masks troubling trends in other groups. If we are to achieve the overall 2020 target and improve health disparities, much more work is needed to address differences in HIV diagnoses that persist (and in some cases are worsening) among specific subpopulations and regions in the United States.  

Intensifying prevention efforts in communities where HIV is concentrated and focusing on interventions that are effective, scalable, and can have the biggest impact are essential to lower all communities’ collective risk of acquiring HIV infection. For this reason, the NHAS has focused on four key populations that data show to have been disproportionately affected by HIV and are at increased risk of becoming newly infected with HIV. The populations were picked based on available data at the time the Strategy was developed. As new data is released, we continue to work as a nation to reduce disparities among these four populations, but also employ strategies for reducing disparities among all populations where disparities are found. The NHAS sets targets for reducing disparities in the rate of new HIV diagnoses among each of these four populations by at least 15% by 2020:

• Gay and bisexual men;
• Young Black gay and bisexual men;
• Black females; and
• People living in the Southern United States.

These indicators monitor disparities in diagnosis rates for disproportionately affected groups by measuring changes in the ratio of the disparity rate for each group (numerator) and the overall population rate (denominator). The ratio provides a measure of disparity, such that the ratio increases as the difference widens between a selected group and the overall population and decreases as the difference narrows. The choice of measuring diagnosis rates, rather than numbers, was made to standardize measures (i.e., per 100,000 population).

In the Monitoring Report [PDF, 2.31 MB] released recently by the Centers for Disease Control and Prevention (CDC), data on progress for HIV diagnoses is assessed for years that have at least 18 months of reporting delay and are considered final. (The most recent year for which data are available, 2015, only had 6 months of reporting delay, so they are considered preliminary and progress is not assessed in this report. As a result, 2014 data is reported as final and 2015 data is reported as preliminary.)

Using data from the Monitoring Report, the table below shows the results for each of the four NHAS disparities indicators for 2014:Black females are the only one of these four subgroups that showed improvement over time and met the 2014 NHAS annual target. Annual NHAS targets for reductions in HIV diagnosis disparities were not met in 2014 for all gay and bisexual men; young Black gay and bisexual men; and those living in the Southern United States. Further, the disparities actually continued to grow among these groups. Since 2010, the disparities in diagnoses for each of these groups have increased indicating that we are moving in the wrong direction.

While subgroup analysis is not available in the Monitoring Report, the Surveillance Report, Diagnoses of HIV Infection in the United States and Dependent Areas, 2015 [PDF, 3.90 MB] provides preliminary data for 2015 that help provide context for each of the disparities indicators:

• Men who have sex with men (MSM) made up about 67% of all new HIV diagnoses in the U.S. and 82% of all new diagnoses among men.

• Black gay men made up about 26% of all new HIV diagnoses and about 39% of all new diagnoses among men who have sex with men.

• Black females made up 61% of all new HIV diagnoses among females.

• People living in the Southern United States made up nearly 52% of all new HIV diagnoses.

This is the second year in a row that these indicators did not meet their annual targets and continued to move in the wrong direction. In response to the data presented in the 2016 NHAS Progress Report [PDF, 367 KB] for these indicators, the National HIV/AIDS Strategy Federal Interagency Workgroup (FIW) formed three ad hoc subgroups to work to determine why these indicators are not improving and what changes to programs, policies, services, and/or investments we can propose that could better move the indicators in the right direction. The FIW works to better coordinate, monitor, and advance Federal efforts toward achieving our national HIV goals.  

In addition to work of the NHAS FIW ad hoc subgroups to address these disparities, the Secretary’s Minority AIDS Initiative Fund (SMAIF) provides funding to programs that improve HIV prevention, care and treatment for MSM, black gay men, black females, and people living in the Southern United States. For example, the SMAIF and HRSA funded program Partnerships for Care (P4C) has enabled health centers and state health departments to expand and improve HIV prevention and care services within communities most impacted by HIV. During the first two years of the demonstration project, the 22 participating health centers provided HIV testing to 77,347 patients; provided medical services to 7,427 HIV-positive patients; and 76% of these patients were virally suppressed.

Enduring disparities in new HIV diagnoses represent significant challenges to preventing new HIV infections and achieving health equity in the United States. In order to reduce these disparities, cost-effective and scalable HIV prevention interventions must be aligned with the HIV epidemic – to those people and places hit hardest by HIV. Reducing these disparities also requires that we strive to diagnose those who do not know they are infected, ramp up immediate linkage to care and treatment for those newly diagnosed, and address barriers to successful treatment and retention in HIV medical care.  

In the next post in our continuing NHAS Indicators series, we will look at indicators highlighting linkage to and retention in HIV medical care. Stay tuned…