Core Indicators for Monitoring EHE (Preliminary Data): HIV Diagnoses and Linkage to HIV Medical Care, 2019 (Reported through December 2019); and Preexposure Prophylaxis (PrEP)— 2018, Updated

The Ending the HIV Epidemic: A Plan for America (EHE) initiative will leverage critical scientific advances in HIV prevention, diagnosis, treatment, and outbreak response [1]. The goal of the initiative is to reduce new HIV infections by 75% in 5 years and by at least 90% in 10 years. Throughout the initiative, the Centers for Disease Control and Prevention (CDC) will routinely release HIV Surveillance Data Tables on the 6 core indicators for EHE to allow for more timely monitoring of progress. The full list of EHE core indicators and their definitions can be found in the Technical Notes of the Core Indicators for Monitoring the Ending the HIV Epidemic Initiative report at https://www.cdc.gov/hiv/pdf/library/reports/surveillance-data-tables/vol-1-no-1/cdc-hiv-surveillance-tables-vol-1-no-1.pdfpdf icon.

The tables included in this report provide preliminary data on HIV diagnoses and linkage to HIV medical care for the year 2019. Updated data on preexposure prophylaxis (PrEP) coverage for the year 2018 (and 2017 for Puerto Rico) are also included. Data for all 3 indicators are provided at the national-, state-, and county-level (EHE Phase I jurisdictions only). See Tabulation and Presentation of Data for details on how the indicators are calculated.

TABULATION AND PRESENTATION OF DATA

Diagnoses of HIV Infection

Diagnoses of HIV infection are the numbers of persons aged ≥13 years whose HIV infection was diagnosed during 2019 (Tables 1a–d).

Data presented were reported (after the removal of personally identifiable information) to CDC’s National HIV Surveillance System (NHSS) through December 31, 2019. 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; the results of anonymous tests are not reported to the confidential, name-based HIV registries of state and local health departments. Therefore, reports of confidential test results may not repre­sent all persons who tested positive for HIV infection.

More information on counting diagnoses of HIV infection can be found at https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-31/index.html (HIV Surveillance Report, 2018 [Updated]).

Linkage to HIV Medical Care

Linkage to HIV medical care within 1 month of HIV diagnosis is measured for persons aged ≥ 13 years whose HIV infection was diagnosed during the spec¬ified month/year, and who resided in any of the jurisdictions (including EHE Phase I jurisdictions) with complete reporting of laboratory data to CDC at the time of diagnosis (Tables 2a–c). The numerator is the number of persons aged ≥ 13 years whose HIV infection was diagnosed during the specified month/year and who had ≥ 1 CD4 or viral load (VL) test within 1 month of HIV diagnosis. The denominator is the number of persons aged ≥ 13 years whose HIV infection was diagnosed during the specified month/year. Data are not provided for states and associated jurisdictions that do not have laws requiring reporting of all CD4 and viral loads, or that have incomplete reporting of laboratory data to CDC. Areas without laws: Idaho, New Jersey, and Pennsylvania. Areas with incomplete reporting: Arizona, Arkansas, Connecticut, Kansas, Kentucky, Vermont, and Puerto Rico.

More information on calculating linkage to care can be found at https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-25-2.pdf pdf icon[PDF – 4 MB] (Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2018).

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 3a–d).

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.

Persons prescribed PrEP

National pharmacy data from the IQVIA Real World Data-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 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 [2–4].

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/African American, Hispanic/Latino, and other. The number of persons prescribed PrEP for each racial/ethnic group presented was extrapolated by applying the racial/ethnic distribution of known records to those for which data on race/ethnicity was unknown.

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 is used to crosswalk between ZIP3s and states/counties using data from (a) the U.S Census Bureau’s American Community Survey (ACS) 5-year estimates by ZIP Code Tabulation Areas (ZCTAs) [5], and (b) the U.S Department of Housing and Urban Development’s ZIP Code Crosswalk Files [6]. Because of reliability concerns, subnational estimates of <40 are not included.

Persons with PrEP indications

ACS and U.S. Census Bureau datasets were used to estimate the number of men who have sex with men (MSM) in a jurisdiction. 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 [7].

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 numbers of persons with indications for PrEP in the 3 major transmission risk groups (MSM, heterosexuals, 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 [8].

The number of MSM in a jurisdiction is determined using the ACS as one of the 3 data sources used to estimate the number of persons with indications for PrEP (i.e., PrEP coverage denominator). However, prior to 2018, the ACS did not include data needed to estimate the number of persons with indications for PrEP in Puerto Rico; consequently, the number of persons with indications for PrEP in Puerto Rico in 2017 was not available. In 2018, the ACS conducted a separate Puerto Rico survey and these data were used to determine the number of persons with indications for PrEP in 2018 for Puerto Rico. In addition, 2017 PrEP coverage for Puerto Rico is now provided using the 2018 denominator for Puerto Rico.

The data sources used to estimate the number of persons with indications for PrEP have different schedules of data availability. Consequently, the availability of a denominator lags the availability of a numerator by approximately 1 year. For this release of the HIV Surveillance Data Tables, 2018 PrEP coverage data have been updated for all jurisdictions and added for Puerto Rico. Data tables for 2018 include updated 2018 denominators and updated 2018 PrEP coverage for national-, state-, and EHE county- level data.

References

1. HHS. What is ‘Ending the HIV Epidemic: A Plan for America’? https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overviewexternal icon. Published October 4, 2019. Accessed July 13, 2020.
2. Wu H, Mendoza MC, Huang YA, Hayes T, Smith DK, Hoover KW. Uptake of HIV pre-exposure prophylaxis among commercially insured persons—United States, 2010–2014. Clin Infect Dis 2017;64(2):144–149. doi:10.1093/cid/ciw701.
3. CDC [Huang YA, Zhu W, Smith DK, Harris N, Hoover KW]. HIV pre-exposure prophylaxis, by race and ethnicity—United States, 2014–2016. MMWR 2018;67(41):1147–1150. doi:10.15585/mmwr.mm6741a3.
4. Furukawa NW, Smith DK, Gonzalez CJ, et al. Evaluation of algorithms used for PrEP surveillance using a reference population from New York City, July 2016–June 2018. Public Health Rep 2020;135(2):202–210. doi:10.1177/0033354920904085
5. U.S. Census Bureau. American Community Survey 5-year data (2009-2018). https://www.census.gov/data/developers/data-sets/acs-5year.2018.htmlexternal icon. Published December 19, 2019. Accessed July 13, 2020.
6. HUD. HUD USPS ZIP code crosswalk files. https://www.huduser.gov/portal/datasets/usps_crosswalk.htmlexternal icon. Published 2019. Accessed July 13, 2020.
7. CDC [Smith DK, Van Handel M, Wolitski RJ, et al]. Vital Signs: Estimated percentages and numbers of adults with indications for pre-exposure prophylaxis to prevent HIV acquisition—United States, 2015. MMWR 2015;64(46):1291–1295. doi:10.15585/mmwr.mm6446a4.
8. 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.2018.05.003.

Suggested Citation

Centers for Disease Control and Prevention. Core indicators for monitoring the Ending the HIV Epidemic initiative: HIV diagnoses and linkage to HIV medical care, 2019 (preliminary data, reported through December 2019); pre-exposure prophylaxis (PrEP)—2018, updated. HIV Surveillance Data Tables 2020;1(No. 2) http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published August 2020. Accessed [date].

On the Web: http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html

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Acknowledgments

Publication of HIV Surveillance Data Tables was made possible by the contributions of the state and territorial health departments and the HIV surveillance programs that provided surveillance data to CDC.

HIV Surveillance Data Tables was prepared by the following staff and contractors of the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC: Anna Satcher Johnson, Zanetta Gant, Ya-lin Huang, Dawn Smith, Norma Harris, Xiaohong Hu, Jianmin Li, Baohua Wu, Daneisha Hawkins, Chan Jin, Shihua Wang, Chenchen Yu, Irene Hall, and Michael Friend and the Web and Consumer Services Team of the Prevention Communications Branch (editing and desktop publishing).

^a Transgender male-to-female” includes individuals who were assigned “male” sex at birth but have ever identified as “female” gender. “Transgender female-to-male” includes individuals who were assigned “female” sex at birth but have ever identified as “male” gender.
^b Additional gender identity examples include “bigender,” “gender queer,” and “two-spirit.”
^c Hispanics/Latinos can be of any race.
^dData have been statistically adjusted to account for missing transmission category, therefore values may not sum to column subtotals and total. Data presented based on sex at birth and may include transgender persons.
^eHeterosexual contact with a person known to have, or to be at high risk for, HIV infection.
^fIncludes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
^g Data are based on residence at time of diagnosis of HIV infection.

^a Transgender male-to-female” includes individuals who were assigned “male” sex at birth but have ever identified as “female” gender. “Transgender female-to-male” includes individuals who were assigned “female” sex at birth but have ever identified as “male” gender.
^b Additional gender identity examples include “bigender,” “gender queer,” and “two-spirit.”
^c Hispanics/Latinos can be of any race.
^d have been statistically adjusted to account for missing transmission category, therefore values may not sum to column subtotals and total. Data presented based on sex at birth and include transgender persons.
^e Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
^f Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified.
^g Data are based on residence at time of diagnosis of HIV infection.

Note. Data are based on residence at time of diagnosis of HIV infection.

Note. Data are based on residence at time of diagnosis of HIV infection.

Abbreviations: CD4, CD4+ T-lymphocyte count (cells/µL) or percentage; VL, viral load (copies/mL). CDC, the Centers for Disease Control and Prevention [footnotes only].
Note. Linkage to HIV medical care was measured by documentation of ≥1 CD4 or VL tests ≤1 month after HIV diagnosis. Data not provided for jurisdictions that do not have laws requiring reporting of all CD4 and viral loads or for areas with incomplete reporting of laboratory data to CDC. Areas without laws: Idaho, New Jersey, and Pennsylvania. Areas with incomplete lab reporting: Arizona, Arkansas, Connecticut, Kansas, Kentucky, Vermont, and Puerto Rico.
^a Transgender male-to-female” includes individuals who were assigned “male” sex at birth but have ever identified as “female” gender. “Transgender female-to-male” includes individuals who were assigned “female” sex at birth but have ever identified as “male” gender.
^b Additional gender identity examples include “bigender,” “gender queer,” and “two-spirit.”
^c Hispanics/Latinos can be of any race.
^d Data have been statistically adjusted to account for missing transmission category, therefore values may not sum to column subtotals and total. Data presented based on sex at birth and include transgender persons.
^e Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
^f Includes persons whose infection was attributed to hemophilia, blood transfusion, or perinatal exposure or whose risk factor was not reported or not identified. Data not displayed because the numbers were too small to be meaningful.

Abbreviations: CD4, CD4+ T -lymphocyte count (cells/µL) or percentage; VL, viral load (copies/mL). CDC, the Centers for Disease Control and Prevention [footnotes only].
Note. Data are based on residence at diagnosis of HIV infection. Linkage to HIV medical care was measured by documentation of ≥1 CD4 or VL tests ≤1 month after HIV diagnosis. Data not provided for states and associated counties that do not have laws requiring reporting of all CD4 and viral loads, or that have incomplete reporting of laboratory data to CDC. Areas without laws: Idaho, New Jersey, and Pennsylvania. Areas with incomplete lab reporting: Arizona, Arkansas, Connecticut, Kansas, Kentucky, Vermont, and Puerto Rico.

Abbreviations: CD4, CD4+ T-lymphocyte count (cells/µL) or percentage; VL, viral load (copies/mL). CDC, the Centers for Disease Control and Prevention [footnotes only].
Note. Data are based on residence at diagnosis of HIV infection. Linkage to HIV medical care was measured by documentation of ≥1 CD4 or VL tests ≤1 month after HIV diagnosis. Data not provided for states and associated counties that do not have laws requiring reporting of all CD4 and viral loads, or that have incomplete reporting of laboratory data to CDC. Areas without laws: New Jersey and Pennsylvania (excluding Philadelphia County). Areas with incomplete reporting: Arizona and Puerto Rico.

Abbreviations: PrEP, preexposure propphylaxis; n/a, not available.
^a Estimated using 2018 data from IQVIA pharmacy database. Data for which values are unknown were not reported thus values may not sum to column total.
^b Estimated using 2018 data from National HIV Surveilance System, National Health and Nutrition Examination Survey, and U.S. Census Bureau’s American Community Survey. Data for which values are unknown were not reported thus values may not sum to column total.
^c PrEP coverage, reported as a percentage, was calculated as the number who have been prescribed PrEP divided by the estimated number of persons who had indications for PrEP.
^d Race/ethnicity data were only available for <40% of persons prescribed PrEP in 2018. Number prescribed PrEP and PrEP coverage for race/ethnicity reported in the table were adjusted applying the distribution of records with known race/ethnicity to records with missing race/ethnicity.

Abbreviation: PrEP, preexposure prophylaxis.
Note. Total number prescribed PrEP included persons from the United States and Puerto Rico and 1,605 with unknown ZIP codes.
^aEstimated using 2018 data from IQVIA pharmacy database.
^bEstimated using data from National HIV Surveillance System, National Health and Nutrition Examination Survey, and U.S. Census Bureau’s American Community Survey, and Puerto Rico Community Survey.
^cPrEP coverage, reported as a percentage, was calculated as the number who have been prescribed PrEP divided by the estimated number of persons who had indications for PrEP.

Abbreviations: PrEP, preexposure propphylaxis; n/a, not available.
^aEstimated using 2018 data from IQVIA pharmacy database.
^bEstimated using data from National HIV Ssurveillance System, National Health and Nutrition Examination Survey, and U.S. Census Bureau’s American Community Survey, and Puerto Rico Community Survey.
^cPrEP coverage, reported as a percentage, was calculated as the number who have been prescribed PrEP divided by the estimated number of persons who had indications for PrEP.
^dData value <40 was not reported due to unreliability.

Abbreviations: PrEP, preexposure propphylaxis; n/a, not available.
Note. PrEP coverage for 2017 for the 50 states and the District of Columbia can be found at: https://www.cdc.gov/hiv/pdf/library/reports/surveillance-data-tables/vol-1-no-1/cdc-hiv-surveillance-tables-vol-1-no-1.pdfpdf icon.
^a Estimated using 2017 data from IQVIA pharmacy database.
^b Estimated using data from National HIV Surveuillance System, National Health and Nutrition Examination Survey, and U.S. Census Bureau’s American Community Survey, and Puerto Rico Community Survey.
^c PrEP coverage, reported as a percentage, was calculated as the number who have been prescribed PrEP divided by the estimated number of persons who had indications for PrEP.
^d Data value <40 was not reported due to unreliability.