Diagnoses of HIV Infection in the United States and Dependent Areas 2021: Technical Notes

A. Surveillance of HIV Infection Overview

This report includes HIV surveillance data through 2021 and reported to CDC’s National HIV Surveillance System (NHSS) through December 31, 2022. The data are from 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) in which laws or regulations require confidential reporting to the jurisdiction (not to CDC), by name, for all persons (adults, adolescents, and children) with confirmed diagnoses of HIV infection. After the removal of personally identifiable information, data from these reports were submitted to CDC. Although AIDS cases have been reported to CDC since 1981, the date of implementation of HIV infection reporting has differed from jurisdiction to jurisdiction. All states, the District of Columbia, and 6 U.S. dependent areas had fully implemented name-based HIV infection reporting by April 2008.

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 reports 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 tests and of self-tests are not reported to the confidential, name-based HIV registries of state and local health departments [10, 11]. 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. Although all jurisdictions use a uniform case report form, surveillance practices in data collection and updating of case records may differ among jurisdictions.

Based on annual standard evaluation results [12], the completeness of reporting of HIV infection, as of December 2022, is estimated to be at least 85% in all but 1 jurisdiction. Data re-release agreements between CDC and state/local HIV surveillance programs require specific levels of cell suppression at the state and county level to ensure confidentiality of personally identifiable information.

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. Death data for years 2020 and 2021 should be interpreted with caution due to excess deaths in the United States population attributed to the COVID-19 pandemic. For additional information, see https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm.

B. Stages of HIV Infection – Case Definitions

Both the 2008 and 2014 HIV case definitions were used to classify HIV infection among persons aged ≥ 13 years and among children [13, 14]. In the following lists, some bulleted items are paraphrases, not quotations, from the published surveillance case definitions. The intention is to emphasize the differences between the 2008 and 2014 case definitions.

B1. 2008 Case Definition

The 2008 case definition was used to classify cases diagnosed through 2013. For persons aged ≥ 13 years, this definition incorporates an HIV infection staging system that includes AIDS (HIV infection, stage 3). The 2008 stages of HIV infection are defined as follows:

• HIV infection, stage 1—No AIDS-defining opportunistic illness (OI) and either CD4+ T-lymphocyte (CD4 lymphocyte) count of ≥ 500 cells/μL or CD4 percentage of total lymphocytes of ≥ 29.
• HIV infection, stage 2—No AIDS-defining OI and either CD4 lymphocyte count of 200–499 cells/μL or CD4 percentage of total lymphocytes of 14–28.
• HIV infection, stage 3 (AIDS) —Documentation of an AIDS-defining OI or either a CD4 lymphocyte count of < 200 cells/μL or CD4 percentage of total lymphocytes of < 14. Documentation of an AIDS-defining OI supersedes a CD4 lymphocyte count or percentage that would not, by itself, be the basis for a stage 3 (AIDS) classification.
• HIV infection, stage unknown—No reported information on AIDS-defining OIs and no information available on CD4 lymphocyte count or percentage.

B2. 2014 Case Definition

The 2014 case definition was used to classify cases diagnosed in 2014 and later. It is similar to the 2008 case definition except for the following:

1. inclusion of criteria for stage 0
2. inclusion of CD4 lymphocyte testing criteria for stage 3 in children
3. changes in the cutoffs for CD4 percentage of total lymphocytes used for classification of stages 1 and 2 in persons aged 6 years and older [3]

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.

C. Tabulation and Presentation of Data

The data in this report include information received by CDC through December 31, 2022. The data are organized into 2 sections: National Profile and Special Focus Profiles. Tables are presented in 2 formats: (1) the first format—labeled “a”—exclude data from the dependent areas (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, the Republic of Palau, and the U.S. Virgin Islands), and (2) the second format—labeled “b”—include data from the dependent areas.

Please use caution when interpreting numbers less than 12, and rates and trends based on these numbers.

C1. Definitions and Data Specifications

C1.1 Diagnoses

In this report, the term diagnosis of HIV infection is defined as a diagnosis of HIV infection regardless of the stage of disease (stage 0, 1, 2, 3 [AIDS], or unknown) and refers to all persons with a diagnosis of HIV infection.

The data on diagnoses of HIV infection reflect the date of diagnosis (diagnosed by December 31, 2021; reported to NHSS as of December 31, 2022), not the date of report to NHSS. In addition,

• data from all areas are included in figures and tables displaying numbers and rates of diagnoses of HIV infection, by selected characteristics, area of residence, and metropolitan statistical area (MSA) (Figures A, 1–6, 12–37; Tables 1a/b–10a/b, 20, 22, and A1).
• tables presenting diagnosis data, region or area of residence reflects the address at the time of HIV diagnosis.
• tables presenting exposure data, only include transgender and AGI persons aged ≥ 13 years at time of diagnosis of HIV infection.

Note. Because of reporting delays, the number of cases diagnosed in a given year may be lower than the numbers presented in later reports; however, fluctuations in the number of diagnoses for a calendar year typically subside after 2 to 3 years of reporting. An evaluation of surveillance data (2016–2020 diagnoses) found that, on average, approximately 80% of HIV diagnoses were reported to CDC during the year of diagnosis and approximately 98% of HIV diagnoses were reported to CDC by the end of the following year.

C1.2 Deaths (Any Cause)

Persons reported to NHSS are assumed alive unless their deaths have been reported to CDC. In addition,

• data for the year 2021 are preliminary and based on death data received by CDC as of December 31, 2022.
• deaths of persons with diagnosed HIV infection (Figures 7–9; Tables 11a/b–14a/b) are included regardless of the cause of death, which may not be due to HIV.
• death data are based on a 12-month reporting delay to allow data to be reported to CDC.
• death data by region or 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; when both residence at death and state where a person’s death occurred are not available, the most recent known address on or before the date of death is used.
• due to incomplete reporting of deaths for the year 2021, death data for Guam, Mississippi, U.S. Virgin Islands, and West Virginia should be interpreted with caution.

C1.3 Prevalence

Prevalence data reflect persons living with diagnosed HIV infection, regardless of stage of disease, at year-end 2021 (Figures 10, 11, 38, and 39; Tables 15a/b–22 and A2). In addition,

• data for the year 2021 are preliminary and based on death data received by CDC as of December 31, 2022.
• for tables presenting prevalence data, region or area of residence is based on most recent known address as of the end of the specified year.
• due to incomplete reporting of deaths for the year 2021, prevalence data for Guam, Mississippi, U.S. Virgin Islands, and West Virginia should be interpreted with caution.

C2. 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.

Rates were computed as follows:

For the 50 states, the District of Columbia, and Puerto Rico, the population denominators used to compute rates were based on the Vintage 2021 postcensal estimates file from the U.S. Census Bureau [15].

• For American Samoa, Guam, the Northern Mariana Islands, the Republic of Palau, and the U.S. Virgin Islands, the population denominators were based on estimates and projections from the U.S. Census Bureau’s International Data Base [16].
• Each rate was calculated by dividing the total number of diagnoses (or deaths or prevalence) for the calendar year by the population for that calendar year and then multiplying the result by 100,000.
• The denominators used for calculating the rates specific to age, sex at birth, and race/ethnicity were computed by applying the appropriate vintage estimates for age, sex at birth, and race/ethnicity for the 50 states and the District of Columbia [15]. The same method was used to calculate the denominators for Puerto Rico, with the exception of race/ethnicity estimates; these data are not available for Puerto Rico (see Note below).
• For the other 5 U.S. dependent areas, estimates from the U.S. Census Bureau’s International Data Base were used for age- and sex-specific population denominators [16].

Note. CDC currently does not provide subpopulation rates for the following:

• Race/ethnicity for the 6 U.S. dependent areas because the U.S. Census Bureau does not collect information from all dependent areas.
• Gender, transmission categories, and exposure categories because of the absence of denominator data from the U.S. Census Bureau, the source of denominator data used for calculating all rates in this report.

C2.1 Disparity Measures

This report includes absolute and relative measures of disparities. The literature recommends use of at least one absolute and one relative disparity measure to monitor the magnitude and direction of disparities [17]. 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 HIV indicators. In addition,

• absolute disparity measures the simple difference between two rates (i.e., Rate₁ − Rate₂). The absolute difference measures the magnitude of the difference, which provides some indication of how many lives could be improved if the difference between the two rates were eliminated or reduced (i.e., preventable cases) [18].
• relative disparity measure is the rate ratio between two rates (i.e., Rate₁ ÷ Rate₂). The relative disparity measures the relative magnitude of the disparity.
• for this report, Rate₂ is the reference group and is based on the lowest group rate with more than 5% of cases.

D. Demographic Information

D1. Age

For this report, age assignments are based on the following:

• For prevalence data, based on the person’s age based on most recent known address as of the end of the specified year.
• For death data, determined by the person’s age at time of death.
• For all other tables, based on the person’s age at the time of HIV diagnosis.

D2. Sex/Gender

D2.1 Assigned Sex at Birth (ASAB)

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

D2.2 Gender

Gender identity refers to a person’s internal understanding of their own gender, or gender with which a person identifies. HIV surveillance personnel collect data on gender identity, when available, from sources such as case report forms submitted by health care or HIV testing providers and medical records, or by matching with other health department databases (e.g., Ryan White program data). A person’s transgender status in NHSS is determined based on two variables: assigned sex at birth and gender identity. Both variables are examined, using a two-step approach, to assess transgender status. Cisgender is a term used to indicate that a person’s assigned sex at birth and current gender identity are the same (i.e., a person assigned male at birth and who currently identifies as a man is a cisgender male).

Categories

• Male: a person assigned “male” sex at birth who identifies as male.
• Female: a person assigned “female” sex at birth who identifies as female.
• Transgender woman/girl: a person assigned “male” sex at birth who identifies as female.
• Transgender man/boy: a person assigned “female” sex at birth who identifies as male.
• Additional gender identity (AGI): a person assigned “male” or “female” sex at birth who does not identify as male, female, transgender woman, or transgender man. AGI includes “bigender,” “gender queer,” and “two-spirit.”

D3. Race and Ethnicity

In the Federal Register [19] 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. Implementation by January 1, 2003, was mandated. At a minimum, data on the following race categories should be collected:

• American Indian or Alaska Native
• Asian
• Black or African American
• Native Hawaiian or other Pacific Islander
• White

Additionally, systems must be able to retain information when multiple race categories are reported. In addition to data on race, data on 2 categories of ethnicity should be collected:

• Hispanic or Latino
• not Hispanic or Latino

The Asian or Pacific Islander category displayed in annual surveillance reports published prior to the 2007 surveillance report was split into 2 categories: (1) Asian and (2) Native Hawaiian or other Pacific Islander. The Asian category (in tables where footnoted) includes the cases in Asian/Pacific Islander persons (referred to as legacy cases) that were reported before the implementation of the new race categories in 2003 (e.g., cases of HIV infection that were diagnosed and reported to CDC before 2003 but that were classified as stage 3 [AIDS] after 2003) and a small percentage of cases that were reported after 2003 but that were reported according to the old race category (Asian/Pacific Islander). In tables of diagnoses of HIV infection during 2017–2021, the Asian category does not include Asian/Pacific Islander cases because these cases were diagnosed after 2003 and were reported to CDC in accordance with OMB’s Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity [19].

This report also presents data for persons for whom multiple race categories are reported (i.e., multiracial). In this report, persons categorized by race were not Hispanic or Latino. The number of persons reported in each race category may, however, include persons whose ethnicity was not reported.

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 [20, 21]. Racial and ethnic differences in health are more likely to reflect profound differences in people’s experience based on the relatively advantaged or disadvantaged position in society into which they are born [21, 22]. Social determinant of health factors, shaped by income, education, wealth, and socioeconomic conditions, vary systematically by race and ethnicity and are important in explaining differences in health outcomes [22].

D4. Transmission Categories

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. For surveillance purposes, a diagnosis of HIV infection is counted only once in the hierarchy of transmission categories [23]. Persons aged ≥13 years with more than 1 reported risk factor for HIV infection are classified in the transmission category listed first in the hierarchy. The exception is male-to-male sexual contact and injection drug use; this group makes up a separate transmission category.

Hierarchical Categories

• Male-to-male sexual contact (MMSC): includes individuals assigned male sex at birth, regardless of current gender identity, who have had sexual contact with other males, and individuals assigned male sex at birth who have had sexual contact with both males and females (i.e., bisexual contact).
• Injection drug use (IDU): includes persons who injected nonprescription drugs or who injected prescription drugs for nonmedical purposes. Also includes injection of drugs prescribed to persons if there is evidence that injection equipment was shared (e.g., syringes, needles, cookers).
• Male-to-male sexual contact and injection drug use (MMSC/IDU): includes individuals assigned male sex at birth, regardless of current gender identity, who have had sexual contact with other males (or with both males and females [i.e., bisexual contact]) and injected nonprescription drugs or injected prescription drugs for nonmedical purposes. Also includes injection of drugs prescribed to persons if there is evidence that injection equipment was shared (e.g., syringes, needles, cookers).
• Heterosexual contact: includes persons who have ever had heterosexual contact with a person known to have, or with a risk factor for, HIV infection.
• Perinatal: includes persons who acquired HIV through mother-to-child transmission.
• Other: includes persons with other risk factors (e.g., blood transfusion, hemophilia) or whose risk factor was not reported or not identified.

Cases of HIV infection reported without a risk factor listed in the hierarchy of transmission categories are classified as “no identified risk (NIR).” Cases classified as NIR include cases that are being followed up by local health department staff; cases in persons whose risk-factor information is missing because they died, declined to be interviewed, or were lost to follow-up; and cases in persons who were interviewed or for whom other follow-up information was available but for whom no risk factor was identified.

Because a substantial proportion of cases of HIV infection are reported to CDC without an identified risk factor, multiple imputation is used to assign a transmission category to these cases [23]. Multiple imputation is a statistical approach in which each missing transmission category is replaced with a set of plausible values that represent the uncertainty about the true, but missing, value [24]. Each resulting data set containing the plausible values is analyzed by using standard procedures, and the results from these analyses are then combined to produce the results. In tables displaying transmission categories, multiple imputation was used for adults and adolescents, but not for children (because the number of cases in children is small, missing transmission categories were not imputed).

D4.2 Exposure category

Exposure category is the term for classifying patient history data (individual risk behaviors or events) by assigning individual risk behaviors or events into mutually exclusive categories. They are meant to convey all the known ways a person could have been exposed to HIV. The exposure category classification was developed as an alternative to the hierarchical transmission category classification. For the presentation of data in this report, exposure category is used for the classification of transgender and AGI persons 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.

Categories

• Sexual contact: includes persons assigned “male” sex at birth, who reported sexual contact with any person. For persons assigned “female” sex at birth, they reported sexual contact with a person assigned “male” sex at birth.
• Injection drug use (IDU): includes persons who inject nonprescription drugs or who injected prescription drugs for nonmedical purposes. Also includes injection of drugs prescribed to persons if there is evidence that injection equipment was shared (e.g., syringes, needles, cookers).
• Sexual contact and IDU: includes persons assigned “male” sex at birth, who reported sexual contact with any person and injected nonprescription drugs or injected prescription drugs for nonmedical purposes. For persons assigned “female” sex at birth, they reported sexual contact with a person assigned “male” sex at birth and injected nonprescription drugs or injected prescription drugs for nonmedical purposes. Also includes injection of drugs prescribed to persons if there is evidence that injection equipment was shared (e.g., syringes, needles, cookers).
• Perinatal: includes persons who acquired HIV through mother-to-child transmission.
• Other: includes persons with other risk factors (e.g., blood transfusion, hemophilia) or whose risk factor was not reported or not identified.

Cases of HIV infection reported without a risk factor listed for exposure categories are classified as “no identified risk (NIR).” Cases classified as NIR include cases that are being followed up by local health department staff; cases in persons whose risk factor information is missing because they declined to be interviewed, were lost to follow-up, or died; and cases in persons who were interviewed or for whom other follow-up information was available but for whom no risk factor was identified.

E. Geographic Designation

E1. U.S. CENSUS REGIONS

Data by region reflect the following:

• For diagnoses, region is based on address at the time of diagnosis of HIV infection (Figures 4, 8, 9, 13, 15, 16, 18, 19, 24, 26, 27, 32, 33; Tables 1a/b–8a/b).
• For prevalence, region is based on most recent known address as of the end of the specified year (Tables 15a/b–19a/b).
• For deaths, region 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 (Figure 8; Tables 11a/b–14a/b).

The 4 regions of residence and 6 dependent areas used in this report are defined by the U.S. Census Bureau as follows:

Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont

Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin

South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia

West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming

U.S. dependent areas: American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, the Republic of Palau, and the U.S. Virgin Islands

E2. Metropolitan Statistical Areas

On March 6, 2020, OMB announced new MSA delineations based on the new standards and Census 2010 data [25]. Table 22 (data on diagnosed HIV infection and prevalence of diagnosed HIV infection) present numbers and rates of diagnoses and prevalence, by MSA, for areas with populations of 500,000 or more. The MSAs listed in these tables were defined according to OMB’s most recent update (March 2020) of statistical areas [25]. In the Federal Register for July 16, 2021, OMB published revised standards for defining MSAs in federal statistical activities [26]. These standards, which provided for the identification of MSAs in the United States and Puerto Rico, will replace the 2010 standards. OMB plans to publish delineations of areas based on the 2020 standards and 2020 Census data in 2023 [26].

F. Limitations of Data and Findings

Readers are encouraged to keep the following caveats and limitations in mind when reviewing and using data presented in the HIV Surveillance Report and other surveillance products.

• Testing patterns. The scope to which routine testing is offered to specific groups and the availability of, and access to, medical care and testing services may influence diagnosis trends.
• Case reporting. Although all jurisdictions use a uniform case report form, reporting and surveillance practices in data collection and case record updates may vary among jurisdictions. Not all persons who received a positive HIV test result may be registered in the confidential, name-based HIV registries of state/local jurisdictions due to the use of anonymous HIV testing and private HIV self-testing. The data presented in this report provide minimum counts of persons for whom HIV infection has been diagnosed and reported to the surveillance system. An evaluation of surveillance data (2016-2020 diagnoses) found that, on average, approximately 80% of HIV diagnoses were reported to CDC during the year of diagnosis and approximately 98% of HIV diagnoses were reported to CDC by the end of the following year. Consequently, these reporting delays may result in lower numbers than those presented in later reports; however, fluctuations in the number of diagnoses for a calendar year typically subside after two to three years of reporting.
• Cases with no identified risk factor. A significant proportion of cases in NHSS are reported without HIV risk factor information. Multiple imputation is used to assign a transmission category to cases reported without HIV risk information [24]; thus, data on transmission category presented in this report do not directly reflect collected case data. Multiple imputation is not used for pediatric cases.
• Duplicates. Case records are routinely reviewed for potential duplicate entries at both the state/local jurisdiction- and national-level, and resolution is completed within and between states. However, there may be cases that appear more than once in the national dataset that have not been deemed duplicates; likewise, there may be cases that have been determined to be duplicates but are unique cases.
• Data availability.
  • Preliminary data. Data are considered preliminary when based on an NHSS dataset created before a 12-month reporting delay has been reached.
  • Provisional data. Data are considered provisional when based on an NHSS dataset created after a 12-month reporting delay has been reached. Diagnoses data in this report are provisional and replace all previously published data on HIV diagnoses for the same data years. The data provided in this report should not be combined with or compared to previously published data.
• Death data. Deaths of persons with diagnosed HIV infection may be due to any cause (i.e., may or may not be related to HIV infection). Deaths for the most recent report year (2021) are considered preliminary and based on a 12-month reporting delay to allow time for death data to be reported to CDC.
• Denominator data. Rates are not provided by race/ethnicity for the 6 U.S. dependent areas and are also not provided for gender, transmission, and exposure categories due to the lack of population, or denominator, data from the U.S. Census. Due to the lack of rates, these demographics were not evaluated in this report for absolute and relative disparities (measures that could improve the understanding of health equity in these populations).

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25. 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.pdf. Published March 6, 2020. Accessed May 2, 2023.
26. 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-areas. Accessed May 2, 2023.
27. Bosh KA, Johnson AS, 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

Additional Resources

The following were prepared by using HIV surveillance data:

• NCHHSTP AtlasPlus [interactive tool for accessing HIV, STD, TB, and hepatitis data]: http://www.cdc.gov/nchhstp/atlas/
• MMWR articles (selected): http://www.cdc.gov/hiv/library/reports/mmwr.html
• Other surveillance reports: http://cdc.gov/hiv/library/reports/hiv-surveillance.html
• Public-use slides updated annually: http://www.cdc.gov/hiv/library/slidesets/

Suggested Readings

CDC. Establishing a holistic framework to reduce inequities in HIV, viral hepatitis, STDs, and tuberculosis in the United States. http://stacks.cdc.gov/view/cdc/11585. Published October 2010. Accessed May 2, 2022.

CDC. Estimated HIV incidence and prevalence in the United States, 2015–2019. HIV Surveillance Supplemental Report 2021;26(No. 1). http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published May 2021. Accessed May 2, 2022.

CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2020. HIV Surveillance Supplemental Report 2022;27(No. 3). http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published May 2022. Accessed May 2022.

CDC. HIV and gay and bisexual men. https://www.cdc.gov/hiv/group/gay-bisexual-men/index.html. Updated October 15, 2021. Accessed May 2, 2022.

CDC. HIV and people who inject drugs. https://www.cdc.gov/hiv/group/hiv-idu.html. Updated March 16, 2022. Accessed May 2, 2022.

CDC. HIV and women. https://www.cdc.gov/hiv/group/gender/women/index.html. Updated March 10, 2022. Accessed May 2, 2022.

CDC. HIV and youth (HIV in the United States by age). https://www.cdc.gov/hiv/group/age/youth/index.html. Updated January 12, 2022. Accessed May 2, 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. Accessed May 2, 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. Accessed May 2, 2022.

CDC [Harris NS, Satcher Johnson A, Huang YA, et al]. Vital Signs: Status of human immunodeficiency virus testing, viral suppression, and HIV preexposure prophylaxis—United States, 2013–2018. MMWR 2019;68(48):1117–1123. https://www.cdc.gov/mmwr/volumes/68/wr/mm6848e1.htm. Accessed May 2, 2022.

CDC [Huang YA, Zhu W, Smith DK, Harris N, Hoover KW]. HIV preexposure prophylaxis, by race and ethnicity—United States, 2014–2016. MMWR 2018;67(41):1147–1150. doi:10.15585/mmwr.mm6741a3

Cohen SM, Gray KM, Ocfemia MC, Johnson AS, Hall HI. The status of the National HIV Surveillance System, United States, 2013. Public Health Rep 2014;129(4):335–341. doi:10.1177/003335491412900408

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.2019.1343

Frieden TR, Foti KE, Mermin J. Applying public health principles to the HIV epidemic—how are we doing? N Engl J Med 2015;373:2281–2287. doi:10.1056/NEJMms1513641

Gant Z, Dailey A, Wang S, Lyons SJ, Watson M, Lee K, Johnson AS. Trends in HIV care outcomes among adults and adolescents in the U.S. South, 2015–2019. Annals of Epidemiology. 2022;71:15–22. doi:https://doi.org/10.1016/j.annepidem.2022.04.011

Nesheim S, Taylor A, Lampe MA, Kilmarx PH, Harris LF, Whitmore S, Griffith J, Thomas-Proctor M, Fenton K, Mermin J. A framework for elimination of perinatal transmission of HIV in the United States. Pediatrics October 2012;130(4):738–744. Doi:10.1542/peds.2012-0194

COVID-19 Suggested Readings

CDC. HIV and COVID-19 basics. https://www.cdc.gov/hiv/basics/covid-19.html https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/hiv.html#:~:text=People%20with%20HIV%20can%20protect,keep%20your%20immune%20system%20healthy. Updated July 12, 2022. Accessed May 2, 2023.

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:http://dx.doi.org/10.15585/mmwr.mm6918e2

Collins J, Niakan K, Schweitzer K, Silseth S. Study of the impact of COVID-19 on HIV testing, diagnosis, and treatment in the United States. Published October 2022. Milliman White Paper available at https://www.milliman.com/en/insight/impact-of-covid-19-on-hiv. Accessed May 2, 2023.

Guidelines Working Groups of the NIH Office of AIDS Research Advisory Council. Guidance for COVID-19 and People with HIV. https://www.oar.nih.gov/hiv-policy-and-research/oarac/hiv-antiretroviral-and-oi-guidelines-working-groups-of-oarac. Updated February 22, 2022. Accessed May 2, 2023.

Hershow RB, WilsonS, 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

Hoover KW, Zhu W, Gant ZC, et al. HIV services and outcomes during the COVID-19 pandemic—United States, 2019–2021. MMWR 2022;71:1505–1510. doi:10.15585/mmwr.mm7148a1

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.2020.37069

Viguerie A, Song R, Johnson AS, Lyles CM, Hernandez A, Farnham PG. Isolating the effect of COVID-19-related disruptions on HIV diagnoses in the United States in 2020. J Acquir Immune Defic Syndr 2023;92(4):293–299. doi:10.1097/QAI.0000000000003140

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.

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:e690–700. doi:10.1016/S2352-3018(21)00239-3

Web Addresses for Reports of State and Local HIV Surveillance

Ending the HIV Epidemic: A Plan for America Initiative, Phase I Areas

To accelerate action to end the HIV epidemic, the U.S. Department of Health and Human Services (HHS) has proposed a plan to reduce new HIV infections in the United States. The Ending the HIV Epidemic: A Plan for America (EHE) initiative, Phase I, implements high-impact HIV prevention, care, treatment, and outbreak response strategies in 48 counties, the District of Columbia, San Juan, Puerto Rico, and 7 states with a substantial rural HIV burden. The goal of the initiative is to reduce new HIV infections by 75% in 5 years, and by 90% in 10 years.

The EHE Phase I jurisdictions include the District of Columbia, San Juan, Puerto Rico, and 48 counties: Arizona—Maricopa County; California—Alameda County, Los Angeles County, Orange County, Riverside County, Sacramento County, San Bernardino County, San Diego County, San Francisco County; Florida—Broward County, Duval County, Hillsborough County, Miami-Dade County, Orange County, Palm Beach County, Pinellas County; Georgia—Cobb County, DeKalb County, Fulton County, Gwinnett County; Illinois—Cook County; Indiana—Marion County; Louisiana—East Baton Rouge Parish, Orleans Parish; Maryland—Baltimore City, Montgomery County, Prince George’s County; Massachusetts—Suffolk County; Michigan—Wayne County; Nevada—Clark County; New Jersey—Essex County, Hudson County; New York—Bronx County, Kings County, New York County, Queens County; North Carolina—Mecklenburg County; Ohio—Cuyahoga County, Franklin County, Hamilton County; Pennsylvania—Philadelphia County; Tennessee—Shelby County; Texas—Bexar County, Dallas County, Harris County, Tarrant County, Travis County; Washington—King County.

EHE Phase I jurisdictions also include the following 7 states with substantial rural HIV burden: Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina.