Monitoring Selected National HIV Prevention and Care Objectives By Using HIV Surveillance Data United States and 6 Dependent Areas, 2020: Technical Notes

A. Surveillance of HIV Infection Overview

This report includes data reported to CDC through December 31, 2021, from all 50 states, the District of Columbia, and 6 U.S. dependent areas (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, the Republic of Palau, and the U.S. Virgin Islands). After the removal of personally identifiable information, data were submitted to CDC.

All data presented in this report are considered provisional (based on a ≥ 12-month reporting delay) and subject to change as additional reports are submitted for HIV cases and HIV surveillance data quality improves with further evaluation of the surveillance system and data repository. Data are based on a 12-month reporting delay to allow sufficient time for HIV-related laboratory results and deaths to be reported to CDC. Because reporting delays can impact the reliability of data presented in this report, caution should be applied when interpreting the results.

Please use caution when interpreting data on diagnoses of HIV infection. HIV surveillance data on persons with diagnosed HIV infection may not be representative of all persons with HIV because not all infected persons have been (1) tested or (2) tested at a time when the infection could be detected and diagnosed. Also, some states offer anonymous HIV testing and some persons complete self-testing at home or in a private location; the results of anonymous and self-tests are not reported to the confidential name-based HIV registries of state and local health departments [11, 12]. Therefore, reports of confidential test results may not represent all persons who tested positive for HIV infection. In addition, testing patterns are influenced by many factors, including the extent to which testing is routinely offered to specific groups and the availability of, and access to, medical care and testing services. The data presented in this report provide minimum counts of persons for whom HIV infection has been diagnosed and reported to the surveillance system. Finally, although all jurisdictions use a uniform case report form, surveillance practices in data collection and updating of case records may differ among jurisdictions.

Please use caution when interpreting laboratory data for persons with diagnosed HIV infection. Laboratory data presented in this report are from 46 jurisdictions (45 states and the District of Columbia) that reported complete CD4+ T-lymphocyte (CD4) and viral load test results to CDC as of December 31, 2021. Data from these jurisdictions represent 89% of all persons aged ≥ 13 years living with diagnosed HIV infection at year-end 2020 in the United States.

Caution: Data for the year 2020 should be interpreted with caution due to the impact of the COVID-19 pandemic on access to HIV testing, care-related services, and case surveillance activities in state/local jurisdictions.

B. Stages of HIV Infection—Case Definitions

Both the 2008 and 2014 HIV case definitions were used to classify HIV infection among adults and adolescents aged ≥ 13 years and among children < 13 years [13, 14].

More information on case definitions can be found in the Technical Notes of the 2020 HIV Surveillance Report at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

C. Areas with Complete Laboratory Reporting

As of December 31, 2021, 46 jurisdictions (45 states and the District of Columbia) had met the following criteria for the collection and reporting of CD4 and viral load test results:

  • The jurisdiction’s laws/regulations required the reporting of all levels of CD4 and viral load results to the state or local health department (Table 11).
  • Laboratories that perform HIV-related testing for the jurisdiction had reported a minimum of 95% of HIV-related test results to the state or local health department.
  • By December 31, 2021, the jurisdiction had reported (to CDC) at least 95% of all CD4 and viral load test results received from January 2020 through September 2021.

The 45 states are Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. Data from these states and the District of Columbia were used to populate Tables 1a–e, 2a–e, 3a–e, and 4a–b.

D. Tabulation and Presentation of Data

D1. Definitions and Data Specifications

D1.1 Stage of Disease at Time of Diagnosis of HIV Infection

Data on persons with HIV infection, stage 3 (AIDS), include persons whose infection has ever been classified as stage 3 (AIDS). These data do not necessarily represent the current stage of disease.

The stages of HIV infection in the 2014 case definition are based on age-specific CD4 lymphocyte counts or percentages of total lymphocytes and are defined as follows:

  • HIV infection, stage 0: First positive HIV test result within 6 months after a negative HIV test result. The stage remains stage 0 until 6 months after the first positive test result. After 6 months, the stage may be classified as 1, 2, 3, or unknown if based on a CD4 test result or the diagnosis of an OI. The diagnosis of an AIDS-defining condition or a low CD4 test result before the 6 months have elapsed does not change the stage from stage 0 to stage 3.
  • HIV infection, stages 1, 2, and 3: Documentation of an AIDS-defining OI (excluding stage 0 as described above) is stage 3. Otherwise, the stage is determined by the lowest CD4 lymphocyte test result:
    • Stage 1—CD4 lymphocyte count of  ≥ 500 or a CD4 percentage of total lymphocytes of  ≥ 26
    • Stage 2—CD4 lymphocyte count of 200–499 or a CD4 percentage of total lymphocytes of 14–25
    • Stage 3—CD4 lymphocyte count of < 200 or a CD4 percentage of total lymphocytes of < 14 or documentation of an AIDS-defining condition.
  • HIV infection, stage unknown: No reported information on AIDS-defining OIs and no information available on CD4 lymphocyte count or percentage.

Because a complete assessment of stage of disease at time of HIV diagnosis relies on complete laboratory data (all CD4 values) so that earlier stages of disease (stage 0 or 1) can be assessed, stage of disease at time of diagnosis was calculated for the 46 jurisdictions that reported complete laboratory data (Tables 1a–e).

Information on stage 3 (AIDS) is available for all 50 states, the District of Columbia, and 6 U.S. dependent areas, even when not all CD4 values are reportable; therefore, stage 3 (AIDS) at time of HIV diagnosis was calculated for persons in all areas (Tables 5a–d).

Stage of disease at time of diagnosis (i.e., HIV infection, stage 0, 1, 2, 3 [AIDS], or unknown; Tables 1a–e) and stage 3 (AIDS) at time of HIV diagnosis (Tables 5a–d) were determined by using the first CD4 test result or documentation of an AIDS-defining condition ≤ 3 months after the HIV diagnosis date during 2020, unless documentation indicated disease stage 0. If ≥ 2 events occurred during the same month and could thus qualify as “first,” the following conditions were applied:

  • If an AIDS-defining condition was documented, the AIDS-defining condition was used; if a CD4 count or a CD4 percentage had been reported and an AIDS-defining condition was documented, the AIDS-defining condition was used.
  • If an AIDS-defining condition was not documented, but a CD4 count and a CD4 percentage had been reported, the CD4 count was used.
  • If an AIDS-defining condition was not documented, but >1 CD4 count had been reported, the lowest CD4 count (indicative of the most severe disease state) was used.
  • If an AIDS-defining condition was not documented and a CD4 count had not been reported, but a CD4 percentage had been reported, the CD4 percentage was used. If >1 CD4 percentage was reported, the lowest CD4 percentage (indicative of the most severe disease state) was used.

For stage of disease at time of diagnosis, infections were classified as “stage unknown” if the month of HIV diagnosis was missing, or if, ≥ 3 months after HIV diagnosis, neither a CD4 count nor a CD4 percentage had been determined and no AIDS-defining condition was documented.

D1.2 Linkage to, and receipt of, HIV Medical Care

The data on linkage to HIV medical care were based on persons whose infection was diagnosed during 2020 and who resided in any of the 46 jurisdictions at the time of diagnosis (Tables 2a–e). Linkage to HIV medical care within 1 month after HIV diagnosis was measured by documentation of  ≥ 1 CD4 (count or percentage) or viral load tests performed ≤ 1 month after HIV diagnosis, including tests performed on the same date as the date of diagnosis.

The data on receipt of HIV medical care were based on persons whose infection was diagnosed by year-end 2019, who resided in any of the 46 jurisdictions as of their most recent known address, and who were alive at year-end 2020 (Tables 3a–e). Receipt of any HIV medical care was measured by documentation of ≥ 1 CD4 or viral load tests performed during 2020. Retention in care (receipt of continuous HIV medical care) was measured by documentation of  ≥ 2 CD4 or viral load tests performed ≥ 3 months apart during 2020.

For analyses of linkage to, and retention in, care, the month and the year of the earliest HIV-positive test result reported to the surveillance system were used to determine the diagnosis date. Test results were excluded if the month of the sample collection was missing. For linkage to care, data were excluded if the month of diagnosis was missing. For receipt of care, retention in care, and viral suppression, data were excluded if the date of death (where applicable) occurred before the year of interest or was missing.

D1.3 Viral Suppression

Viral suppression was measured among persons whose infection was diagnosed by year-end 2019, who resided in any of the 46 jurisdictions as of their most recent known address during 2020, and who were alive at year-end 2020 (Tables 4a/b). Viral suppression was defined as a viral load result of < 200 copies/mL at the most recent viral load test. The cutoff value of < 200 copies/ mL was based on the following definition of virologic failure: viral load of ≥ 200 copies/mL. If multiple viral load tests were performed during the same month and could thus qualify as “most recent,” the highest viral load (most severe) was selected. If the numerical result was missing or the result was a logarithmic value, the interpretation of the result (e.g., below limit) was used to determine viral suppression. Virologic failure may indicate lack of adherence to ART.

Viral suppression within 6 months of diagnosis was measured for persons whose infection was diagnosed during 2020 and who resided in any of the 46 jurisdictions at the time of diagnosis (Tables 2a–e). Viral suppression was defined as a viral load result of <  200 copies/mL at any viral load test within 6 months of an HIV diagnosis made during 2020.

D1.4 Deaths

Monitoring receipt of HIV medical care, retention in HIV medical care, viral suppression at most recent test, deaths and survival of persons with diagnosed HIV infection is dependent upon complete death ascertainment conducted by HIV surveillance programs for reporting to CDC. Due to incomplete reporting of deaths for the year 2020, death data for Guam, Kansas, North Carolina, Puerto Rico, South Carolina, and Vermont should be interpreted with caution.

More information on deaths can be found in the Technical Notes of the 2020 HIV Surveillance Report at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

D1.5 Survival Analyses

The Kaplan-Meier method was used to estimate the probability of survival (Tables 7a–f) for >3 years (36 months) for persons with diagnosed HIV infection and for persons whose infection had ever been classified as stage 3 (AIDS). To allow ≥ 3 years from the time of HIV diagnosis to a death date on or before December 31, 2020, tables were limited to data on persons whose diagnosis or stage 3 (AIDS) classification was made during 2012–2017. The results of survival analyses for areas with < 100 diagnoses per year (i.e., 600 during the 6-year period) were unstable and therefore are not presented in this report.

D1.6 Perinatally Acquired HIV Infection

Table 9a presents data for infants with infection attributed to perinatal transmission and reported to NHSS through December 2021. The data include all persons reported to NHSS with infection attributed to perinatal exposure, regardless of place of birth. Table 9b presents a subset of data from Table 9a: the data include only the persons whose case record denoted the United States as place of birth or residence at birth. The data on persons with perinatally acquired infection that are presented in Table 9b do not include persons who were born in a U.S. dependent area or a foreign country or whose residence at birth was unknown or missing from the case record.

D1.7 Preexposure Prophylaxis (PrEP) Coverage

PrEP coverage, reported as a percentage, is defined as the number of persons aged ≥ 16 years classified as having been prescribed PrEP during the specified year divided by the estimated number of persons aged ≥ 16 years who had indications for PrEP during the specified year (Tables 8a/b, A5).

Number of persons prescribed, which is reported as a case count, is defined as the number of persons aged ≥ 16 years classified as having been prescribed PrEP during the specified year.

PrEP coverage is an EHE indicator that is not a reportable disease or condition and is not reported to NHSS. Multiple data sources, described below, are used to calculate PrEP coverage. Please use caution when interpreting PrEP data. Different data sources were used in the numerator and denominator to calculate PrEP coverage.

D1.7.1 Persons Prescribed PrEP

National pharmacy data from the IQVIA Real-World Longitudinal Prescriptions database (hereafter, IQVIA database) are used to classify persons aged ≥ 16 years who have been prescribed PrEP in the specific year. The IQVIA database captures prescriptions from all payers and represents approximately 92% of all prescriptions from retail pharmacies and 60%–86% from mail-order outlets in the United States. The database does not include prescriptions from some closed health care systems that do not make their prescription data available to IQVIA. Therefore, these are minimum estimates of PrEP coverage. The database includes antiretroviral drugs prescribed, demographic variables of persons to whom the drugs were prescribed, and medical claims for these persons. IQVIA acquires medical claims and race/ethnicity data from various sources, including ambulatory, hospital, and consumer databases, and links these data to persons in the prescription database. The annual number of persons classified as having been prescribed PrEP was based on a validated algorithm that discerns whether tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) were prescribed for PrEP after excluding prescriptions for HIV treatment, hepatitis B treatment, or HIV postexposure prophylaxis [15–17]. Tenofovir alafenamide and emtricitabine (TAF/FTC) was approved as an alternative drug for PrEP by the U.S. Food and Drug Administration (FDA) in October 2019. Starting in 2019, TAF/FTC was included in the algorithm to classify the number of persons prescribed PrEP.

The number of persons classified as having been prescribed PrEP is reported by sex, age group, and race/ethnicity. Transmission category data are not available in the IQVIA database and race/ethnicity data are available for < 40% of persons with PrEP prescriptions. Please use caution when interpreting PrEP data by race/ethnicity. Race/ethnicity categories available in the IQVIA data include White, Black, Hispanic/Latino, and other. The number of persons prescribed PrEP for each racial/ethnic group presented in this report was extrapolated by applying the racial/ethnic distribution of known records to those for which data on race/ethnicity were unknown.

D1.7.2 Preexposure Prophylaxis (PrEP) Coverage—Geographic Designations

In the IQVIA database, a person’s location is reported as a 3-digit ZIP code prefix (hereafter, ZIP3) assigned by the U.S. Postal Service. To estimate the number of persons prescribed PrEP at the state or county level, a probability-based approach used to crosswalk between ZIP3s and states/counties by using the most recent data from (a) U.S Census Bureau’s American Community Survey (ACS) 5-year estimates by ZIP code Tabulate Area (ZCTA) [18], and (b) the U.S. Department of Housing and Urban Development’s ZIP Code Crosswalk Files [19]. Because of reliability concerns, subnational estimates of <50 are not included in this report.

D1.7.3 Persons with Indications for PrEP

ACS and U.S. Census Bureau files were used to estimate the number of MSM (men who have sex with men) in a jurisdiction [20, 21]. Next, behavioral data from the National Health and Nutrition Examination Survey (NHANES) were used to estimate the proportion of HIV-negative MSM with indications for PrEP [22]. For 2018 denominator, this proportion was updated with recent NHANES data.

The number of HIV-negative MSM with indications for PrEP was multiplied by the ratio of percentage of HIV diagnoses during the specified year attributed to other major transmission risk groups compared to the percentage among MSM in a given state or county. The estimated number of persons with indications for PrEP in the 3 major transmission risk groups (MSM, heterosexuals, PWID [persons who inject drugs]) in each jurisdiction were then summed to yield a state or county-specific estimate. State estimates were then summed for a national total of persons with indications for PrEP [23]. Jurisdictional estimates were rounded to the nearest 10.

The tables included in this report provide updated data on PrEP coverage for the year 2020 by using the IQVIA data reported through September 2021. IQVIA conducts data quality assurance activities. As a result, the number of persons classified as having been prescribed PrEP in a given year might change from time to time. The impact of the changes may vary by demographic category nationally and by jurisdiction.

The data sources used to estimate the number of persons with indications for PrEP have different schedules of availability. Consequently, the availability of a denominator lags the availability of a numerator by approximately 1 year. PrEP coverage data with a lagged denominator are considered preliminary. For this release of the Monitoring report, 2018 denominators were used for 2018, 2019, and 2020 PrEP coverage data. In addition to being preliminary, data for the year 2020 should be interpreted with awareness of the impact of the COVID-19 pandemic on filling PrEP prescriptions in state/local jurisdictions [24].

D1.8 Measures of Disparities

Disparity measures include absolute and relative measures. The literature recommends use of at least one absolute and one relative disparity measure to monitor the magnitude and direction of disparities [25, 26]. The absolute rate difference and the relative rate ratio disparity measures were chosen because they are used by federal initiatives—Healthy People 2030, NHAS, and EHE—to measure progress in the social determinants of health (SDOH) and HIV-related indicators. This report uses the analytic approach used in Healthy People 2030 to assess the status of the overall outcomes relative to the proposed, national targets of 95% for linkage to HIV medical care and viral suppression and 50% for PrEP coverage [2].

We measured disparities for the 2 outcomes by selected characteristics (i.e., race/ethnicity, transmission category, and geographic area) and chose either the 95% outcome target or the group with the highest percentage for each outcome as our reference point to highlight opportunities for improvement. Disparities were measured for linkage to care, viral suppression, and PrEP coverage using the following measures:

1) The absolute disparity measure is the absolute or maximal percentage difference that measures HIV-related disparities comparing the difference between the population groups with the highest and lowest percentage for that outcome to their respective targets (e.g., 95% for linkage to care and viral suppression, 50% for PrEP coverage; meeting the target equals 0) and to each other (e.g., between the population group with the highest and lowest percentage for that outcome).

2) The relative disparity measures are the maximal percentage ratio and summary percentage ratio. Maximal percentage ratio is the ratio between the group with the highest and lowest percentage for an outcome to their respective targets (e.g., 95% for linkage to care and viral suppression, 50% for PrEP coverage; meeting the target equals 1) and to each other (e.g., between the population group with the highest and lowest percentage for that outcome). Summary percentage ratio is the ratio between the average of the percentages of all other groups [excluding the group with the highest percentage] and the group with the highest percentage for an outcome.

D2. Rates

Rates per 100,000 population were calculated for (1) the numbers of diagnoses of HIV infection, (2) the numbers of deaths of persons with diagnosed HIV infection, and (3) the numbers of persons living with diagnosed HIV infection. In the tables displaying data on perinatally acquired HIV infection (Tables 9a/b), rates were calculated per 100,000 live births [27].

More information on rates can be found in the Technical Notes of the 2020 HIV Surveillance Report at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

D2.1 Rates of Deaths

In tables displaying data on deaths of persons with diagnosed HIV infection and deaths of persons with infection ever classified as stage 3 (AIDS) (Tables 6a–f), rates were calculated in 3 ways:

  • Rates of deaths per 100,000 population: Each rate was calculated by dividing the total number of deaths for the calendar year by the population for that calendar year and then multiplying the result by 100,000.
  • Rates of deaths per 1,000 persons living with diagnosed HIV infection or living with infection ever classified as stage 3 (AIDS): Rates were calculated by dividing the reported total number of deaths of persons with diagnosed HIV infection (or with infection classified as stage 3 [AIDS]) during the calendar year by the sum of the number of persons living with a diagnosis of HIV infection (or with infection classified as stage 3 [AIDS]) at the end of the previous calendar year plus the number of diagnoses of HIV infection (or stage 3 [AIDS] classification) during the current calendar year; the result was then multiplied by 1,000.
  • Age-adjusted rates of deaths per 100,000 population and per 1,000 persons living with diagnosed HIV infection or living with infection ever classified as stage 3 (AIDS): Tables 6c and 6f include age-adjusted rates by area of residence in addition to crude rates. A standard population distribution was used to adjust death rates per 100,000 population and per 1,000 persons living with diagnosed HIV infection (or with infection ever classified as stage 3 [AIDS]). The age-adjusted rates are rates that would have existed if the age distribution of the designated population and the age distribution of the standard population were the same. The use of the U.S. 2000 standard population in calculating age-adjusted rates was based on recommendations by the National Center for Health Statistics [28, 29].

E. Demographic Information

E1. Age

All tables in this report reflect data on persons aged 13 years and older, with the exception of Tables 8a/b (PrEP coverage) and Tables 9a/b (perinatally acquired HIV infection, birth years 2016–2020).

  • Tables 3a–e and 4a/b (receipt of care and viral suppression): age was based on the person’s age at year-end 2019.
  • Tables 6a–f (deaths): age was based on the person’s age at the time of death.
  • All other tables: age was based on the person’s age at the time of HIV diagnosis.

E2. Sex and Gender

E2.1 Sex assigned at birth

Sex designations in this report are based on a person’s sex assigned at birth.

E2.2 Gender

Gender identity refers to a person’s internal understanding of their own gender, or gender with which a person identifies.

More information on gender can be found in the Technical Notes of the 2020 HIV Surveillance Report at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

E3. Race and Ethnicity

In the Federal Register [30] for October 30, 1997, the Office of Management and Budget (OMB) announced the Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity.

Race and ethnicity are not risk factors but are instead markers for many underlying problems of greater relevance to health, including socioeconomic status and cultural behavior-characteristics, which are social and not biological [31, 32]. Racial and ethnic differences in health are more likely to reflect profound differences in people’s experiences based on the relatively advantaged or disadvantaged position in society into which they are born [32, 33]. SDOH factors, shaped by income, education, wealth, and socioeconomic conditions, vary systematically by race and ethnicity and are important in explaining differences in health outcomes [33].

Demographic information for the live birth registry is based on that of the mother [27]. Therefore, Tables 9a/b, which present estimated numbers and rates of perinatally acquired HIV infection, categorize race/ethnicity according to the mother’s race/ethnicity.

More information on race and ethnicity can be found in the Technical Notes of the 2020 HIV Surveillance Report at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

E4. Transmission/Exposure Categories

E4.1 Transmission Category

Transmission category is the term for the classification of cases that summarizes a person’s (aged ≥ 13 years) possible HIV risk factors; the summary classification results from selecting, from the presumed hierarchical order of probability, the 1 (single) risk factor most likely to have been responsible for transmission [34, 35].

More information on transmission categories can be found in the Technical Notes of the 2020 HIV Surveillance Report at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

E4.2 Exposure Category

Exposure category is the term for the classification of cases in transgender and AGI persons aged ≥ 13 years based on the risk factors that may have been responsible for HIV transmission; classification has no presumed hierarchical order of probability, except for rare circumstances where route of transmission has been confirmed through investigation. The categories are mutually exclusive. Data were not statistically adjusted to account for missing exposure category.

More information on exposure categories can be found in the Technical Notes of the 2020 HIV Surveillance Report at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

F. Geographic Designation

F1. Area of Residence

Data by area of residence reflect the address at the time of stage 3 (AIDS) classification or at the time of diagnosis of HIV infection for Tables 1b, 2b, 5c/d, , 7c/f, and A1–A2. In Tables 3b, 4b, and A3, area of residence is based on most recent known address as of December 31 of the specified year. For the death tables (6c/f), area of residence is based on residence at death. When information on residence at death is not available, the state where a person’s death occurred is used. For PrEP data, please see the Preexposure Prophylaxis (PrEP) Coverage—Geographic Designations section.

F2. U.S. Census Regions

Data by region reflect the address at the time of diagnosis of HIV infection for tables that present number of diagnoses (Tables 1b, 2b, 5a/b, 7a/b, 7d/e). In Tables 3b and 4b, region is based on most recent known address as of December 31 of the specified year. For the death tables (6a/b, 6d/e), region is based on residence at death.

F3. Population Area of Residence

In the Federal Register for July 16, 2021, OMB published revised standards for defining metropolitan statistical areas (MSAs) in federal statistical activities [36]. These standards, which provided for the identification of MSAs in the United States and Puerto Rico, replaced the 2010 standards. The adoption of the new standards was effective as of July 16, 2021. On March 6, 2020, OMB announced new MSA delineations based on the new standards and Census 2020 data [37]. Data by population area of residence reflect the address at the time of stage 3 (AIDS) classification or at the time of diagnosis of HIV infection for Tables 1a/c, 2a/c, 5a, and 7a/d. For Tables 3a/c and 4a, population area of residence is based on the most recent known address as of December 31 of the specified year. For the death tables (6a/d), population area of residence is based on residence at death. The MSAs listed in these tables were defined according to OMB’s most recent update (March 2020) of statistical areas [37].

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  23. CDC [Smith DK, Van Handel M, Grey J]. Estimates of adults with indications for HIV pre-exposure prophylaxis by jurisdiction, transmission risk group, and race/ethnicity, United States, 2015. Ann Epidemiol 2018;28(12):850–857.e9. doi:10.1016/j.annepidem.2018.05.003external icon
  24. CDC [Huang YA, Zhu W, Wiener, et al]. Impact of COVID-19 on HIV pre-exposure prophylaxis prescriptions in the United States—a time-series analysis. Clin Infect Dis 2022;ciac038. doi: 10.1093/cid/ciac038external icon
  25. Keppel K, Pamuk E, Lynch J, et al. Methodological issues in measuring health disparities. Vital Health Stat 2 2005;141:1–16. https://pubmed.ncbi.nlm.nih.gov/16032956/external icon
  26. Penman-Aguilar A, Talih M, Huang D, Moonesinghe R, Bouye K, Beckles G. Measurement of health disparities, health inequities, and social determinants of health to support the advancement of health equity. J Public Health Manag Pract 2016;22(Suppl 1):S33–S42. doi:10.1097/PHH.0000000000000373external icon
  27. Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: final data for 2018. Natl Vital Stat Rep 2019;68(13):1–47. https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_13-508.pdfpdf icon
  28. Anderson RN, Rosenberg HM. Age standardization of death rates: implementation of the year 2000 standard. Natl Vital Stat Rep 1998;47(3):1–16, 20. https://www.cdc.gov/nchs/data/nvsr/nvsr47/nvs47_03.pdfpdf icon
  29. Klein RJ, Schoenborn CA. Age adjustment using the 2000 projected U.S. population. Healthy People 2010 Stat Notes 2001;(20):1–9. http://www.cdc.gov/nchs/data/statnt/statnt20.pdfpdf icon. Accessed May 12, 2022.
  30. Office of Management and Budget. Revisions to the standards for the classification of federal data on race and ethnicity. Federal Register 1997;62(210):58782–58790. http://go.usa.gov/xnV9Texternal icon
  31. CDC. Use of race and ethnicity in public health surveillance summary of the CDC/ATSDR workshop. MMWR 1993;42(RR-10):1–28. https://www.cdc.gov/mmwr/preview/mmwrhtml/00021729.htm
  32. Doubeni CA, Simon M, Krist AH. Addressing systemic racism through clinical preventive service recommendations from the US Preventive Services Task Force. JAMA 2021;325(7):627–628. doi:10.1001/jama.2020.26188external icon
  33. Braveman PA, Egerter SA, Mockenhaupt RE. Broadening the focus: The need to address the social determinants of health. Am J Prev Med 2011;40(1):S4–S18. doi.org/10.1016/j.amepre.2010.10.002external icon
  34. Harrison KM, Kajese T, Hall HI, Song R. Risk factor redistribution of the national HIV/AIDS surveillance data: an alternative approach. Public Health Rep 2008;123(5):618–627. doi:10.1177/003335490812300512external icon
  35. Rubin, DB. Multiple Imputation for Nonresponse in Surveys. New York: John Wiley & Sons Inc; 1987.
  36. Office of Management and Budget. 2020 Standards for delineating core based statistical areas. Federal Register 2021;86(134):37770–37778. https://www.federalregister.gov/documents/2021/07/16/2021-15159/2020-standards-for-delineating-core-based-statistical-areasexternal icon. Accessed May 2, 2022.
  37. Office of Management and Budget. Revised delineations of metropolitan statistical areas, micropolitan statistical areas, and combined statistical areas, and guidance on uses of the delineations of these areas. OMB Bulletin 20-01. https://www.whitehouse.gov/wp-content/uploads/2020/03/Bulletin-20-01.pdfpdf iconexternal icon. Published March 6, 2020. Accessed May 2, 2022.

Suggested Readings

CDC. Establishing a holistic framework to reduce inequities in HIV, viral hepatitis, STDs, and tuberculosis in the United States: an NCHHSTP white paper on social determinants of health, 2010. http://go.usa.gov/AH2zexternal icon. Accessed May 12, 2022.

CDC [Johnson Lyons S, Dailey AF, Yu C, Satcher Johnson A]. Care outcomes among Black or African American persons with diagnosed HIV in rural, urban, and metropolitan statistical areas—42 U.S. jurisdictions, 2018. MMWR 2021;70(7):97–103. https://www.cdc.gov/mmwr/volumes/70/wr/mm7007a1.htm. Accessed May 12, 2022.

CDC [Gant Z, Dailey A, Hu X, Satcher Johnson A]. HIV care outcomes among Hispanics or Latinos with diagnosed HIV infection—United States, 2015. MMWR 2017;66(40):1065–1072. http://www.cdc.gov/mmwr/volumes/66/wr/mm6640a2.htm. Accessed May 12, 2022.

CDC [Singh S, Mitsch A, Wu B]. HIV care outcomes among men who have sex with men with diagnosed HIV infection—United States, 2015. MMWR 2017;66(37):969–974. http://www.cdc.gov/mmwr/volumes/66/wr/mm6637a2.htm. Accessed May 12, 2022.

CDC [Bosh KA, Satcher Johnson A, Hernandez AL, et al]. Vital Signs: Deaths among persons with diagnosed HIV infection, United States, 2010–2018. MMWR 2020;69(46):1717–1724. doi:10.15585/mmwr.mm6946a1

CDC [Siddiqi A, Hu X, Hall HI]. Mortality among blacks or African Americans with HIV infection—United States, 2008–2012. MMWR 2015;64(04):81–86. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6404a2.htm. Accessed May 12, 2022.

CDC [Crepaz N, Dong X, Wang X, Hernandez AL, Hall HI]. Racial and ethnic disparities in sustained viral suppression and transmission risk potential among persons receiving HIV care—United States, 2014. MMWR 2018;67(04):113–118. https://www.cdc.gov/mmwr/volumes/67/wr/mm6704a2.htm. Accessed May 12, 2022.

CDC [Branson BM, Handsfield HH, Lampe MA, et al]. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55(RR-14):1–17. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Accessed May 12, 2022.

CDC [Selik RM, Mokotoff ED, Branson B, Owen SM, Whitmore S, Hall HI]. Revised surveillance case definition for HIV infection—United States, 2014. MMWR 2014;63(RR-03):1–10. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm. Accessed May 12, 2022.

CDC [Schneider E, Whitmore S, Glynn MK, Dominguez K, Mitsch A, McKenna MT]. Revised surveillance case definitions for HIV infection among adults, adolescents, and children aged < 18 months and for HIV infection and AIDS among children aged 18 months to < 13 years—United States, 2008. MMWR 2008;57(RR-10):1–12.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5710a1.htm. Accessed May 12, 2022.

Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending the HIV Epidemic: a plan for the United States. JAMA 2019;321(9):844–845. doi:10.1001/jama.2019.1343external icon

Greenberg AE, Purcell DW, Gordon CM, Barasky RJ, del Rio C. Addressing the challenges of the HIV continuum of care in high-prevalence cities in the United States. J Acquir Immune Defic Syndr 2015;69(suppl 1):S1–S7. doi:10.1097/QAI.0000000000000569external icon

Hess KL, Hall HI. HIV viral suppression, 37 states and the District of Columbia, 2014. J Community Health 2018;43(2):338–347. doi:10.1007/s10900-017-0427-3external icon

U.S. Department of Health and Human Services. What is ‘Ending the HIV Epidemic in the U.S.’? https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overviewexternal icon. Updated March 31, 2021. Accessed May 12, 2022.

Institute of Medicine. Monitoring HIV care in the United States: indicators and data systems [consensus report]. http://www.nap.edu/read/13225/chapter/1external icon. Published March 15, 2012. Accessed May 12, 2022.

Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/whats-new-guidelinesexternal icon. Updated February 24, 2021. Accessed May 12, 2022.

COVID-19 Suggested Readings

CDC [Schuchat A, CDC COVID-19 Response Team]. Public health response to the initiation and spread of pandemic COVID-19 in the United States, February 24–April 21, 2020. MMWR 2020;69(18):551–556. doi:10.15585/mmwr.mm6918e2

Guidelines Working Groups of the NIH Office of AIDS Research Advisory Council. Guidance for COVID-19 and people with HIV. https://clinicalinfo.hiv.gov/en/guidelines/guidance-covid-19-and-people-hiv/guidance-covid-19-and-people-hivexternal icon. Updated February 22, 2022. Accessed March 22, 2022.

Hershow RB, Wilson S, Bonacci RA, et al. Notes from the Field: HIV outbreak during the COVID-19 pandemic among persons who inject drugs—Kanawha County, West Virginia, 2019–2021. MMWR 2022;71(2):66–68. doi:10.15585/mmwr.mm7102a4

CDC. HIV and COVID-19 basics. https://www.cdc.gov/hiv/basics/covid-19.html. Updated February 4, 2022. Accessed March 21, 2022.

Tesoriero JM, Swain CE, Pierce JL, et al. COVID-19 outcomes among persons living with or without diagnosed HIV infection in New York State. JAMA Netw Open 2021;4(2):e2037069. doi:10.1001/jamanetworkopen.2020.37069external icon

Weiser JK, Tie Y, Beer L, Neblett Fanfair R, Shouse RL. Racial/Ethnic and income disparities in the prevalence of comorbidities that are associated with risk for severe COVID-19 among adults receiving HIV care, United States, 2014–2019; J Acquir Immune Defic Syndr 2020;86(3):297–304. doi:10.1097/QAI.0000000000002592external icon

Yang X, Sun J, Patel RC, et al. Associations between HIV infection and clinical spectrum of COVID-19: a population level analysis based on US National COVID Cohort Collaborative (N3C) data. Lancet HIV 2021;8(11):e690–700. doi:10.1016/S2352-3018(21)00239-3external icon