HIV Care Outcomes Among Blacks with Diagnosed HIV — United States, 2014

Since the release of the National HIV/AIDS Strategy (NHAS) (1) and the establishment of the federal Human Immunodeficiency Virus (HIV) Care Continuum Initiative (2), federal efforts have accelerated to improve and increase HIV testing, care, and treatment and to reduce HIV-related disparities in the United States. National HIV Surveillance System (NHSS)* data are used to monitor progress toward reaching NHAS goals,† and recent data indicate that blacks have lower levels of care and viral suppression than do persons of other racial and ethnic groups (3). Among persons with HIV infection diagnosed through 2012 who were alive at year-end 2013, 68.1% of blacks received any HIV medical care compared with 74.4% of whites (3). CDC used NHSS data to describe HIV care outcomes among blacks who received a diagnosis of HIV. Among blacks with HIV infection diagnosed in 2014, 21.9% had infection classified as HIV stage 3 (acquired immunodeficiency syndrome [AIDS]) at the time of diagnosis compared with 22.5% of whites; 71.6% of blacks were linked to care within 1 month after diagnosis compared with 79.0% of whites. Among blacks with HIV infection diagnosed through 2012 who were alive on December 31, 2013, 53.5% were receiving continuous HIV medical care compared with 58.2% of whites; 48.5% of blacks achieved viral suppression compared with 62.0% of whites. Intensified efforts and implementation of effective interventions and public health strategies that increase engagement in care and viral suppression among blacks (1,4) are needed to achieve NHAS goals.

Since the release of the National HIV/AIDS Strategy (NHAS) (1) and the establishment of the federal Human Immunodeficiency Virus (HIV) Care Continuum Initiative (2), federal efforts have accelerated to improve and increase HIV testing, care, and treatment and to reduce HIV-related disparities in the United States. National HIV Surveillance System (NHSS)* data are used to monitor progress toward reaching NHAS goals, † and recent data indicate that blacks have lower levels of care and viral suppression than do persons of other racial and ethnic groups (3). Among persons with HIV infection diagnosed through 2012 who were alive at year-end 2013, 68.1% of blacks received any HIV medical care compared with 74.4% of whites (3). CDC used NHSS data to describe HIV care outcomes among blacks who received a diagnosis of HIV. Among blacks with HIV infection diagnosed in 2014, 21.9% had infection classified as HIV stage 3 (acquired immunodeficiency syndrome [AIDS]) at the time of diagnosis compared with 22.5% of whites; 71.6% of blacks were linked to care within 1 month after diagnosis compared with 79.0% of whites. Among blacks with HIV infection diagnosed through 2012 who were alive on December 31, 2013, 53.5% were receiving continuous HIV medical care compared with 58.2% of whites; 48.5% of blacks achieved viral suppression compared with 62.0% of whites. Intensified efforts and implementation of effective interventions and public health strategies that increase engagement in care and viral suppression among blacks (1,4)  In the 33 jurisdictions, 12,269 blacks received a diagnosis of HIV infection in 2014. Among these, 21.9% had infections classified as stage 3 at diagnosis (Table 1). Among males, 20.9% had a stage 3 classification, compared with 24.8% of females. The highest percentage of infections classified as stage 3 among different age groups were reported in persons aged ≥55 years (38.2%); stage 3 classifications increased with age group. By transmission category, males with infection attributed to injection drug use (IDU) had the highest percentage (32.5%) of infections classified as stage 3, followed by males with infection attributed to heterosexual contact (32.2%).
Overall, 8,780 (71.6%) of the 12,269 blacks with HIV infection diagnosed during 2014 were linked to care ≤1 month after HIV diagnosis; the percentage of persons linked to care increased with increasing age group (Table 2). Overall, 70.0% of males and 76.2% of females were linked to care. By transmission category and age group, males aged 13-24 years with infection attributed to male-to-male sexual contact and IDU accounted for the lowest percentage of persons linked to care (54.9%), followed by males aged 25-34 years with infection attributed to heterosexual contact (63.0%).
Among 257,316 blacks aged ≥13 years living with diagnosed HIV in 33 jurisdictions on December 31, 2013, approximately half (53.5%) were retained in care (Table 3), including 52.4% of males and 55.6% of females. A lower percentage of persons aged 13-34 years were retained in care (50.3%) than were persons aged ≥35 years (54.4%). By transmission category and age group, males aged 25-34 years with infection attributed to IDU accounted for the lowest percentage retained in care (38.1%), followed by males aged 13-24 years with infection attributed to heterosexual contact (39.4%). VL suppression at the most recent test was achieved by 48.5% of persons (Table 3); a higher percentage of females had suppressed VL (49.8%) than did males (47.9%). Among all age groups, the lowest level of VL suppression was among persons aged 13-24 years (39.7%); VL suppression increased with increasing age group. Females aged 13-24 years with infection attributed to IDU had the lowest level of viral suppression (29.7%), followed by males aged 13-24 years with infection attributed to heterosexual contact (31.2%).

Discussion
In 2014, among blacks aged ≥13 years with diagnosed HIV, approximately one in five (21.9%) infections were classified as stage 3 (AIDS) at the time of diagnosis and 71.6% were linked to care within 1 month of diagnosis. Among all blacks living with diagnosed HIV at year-end 2013 in the 33 jurisdictions with complete laboratory reporting, 53.5% were retained in care and 48.5% had achieved viral suppression. These percentages are far below the NHAS 2020 goals of 85% linkage to care, 90% retention in care, and 80% VL suppression, and are also below the percentages of whites who were linked to care, retained in care and with VL suppression (79.0%, 58.2%, and 62.0%, respectively). Improving health outcomes for blacks living with HIV infection is necessary to reduce HIV in the United States. Prompt linkage to care after diagnosis allows early initiation of HIV treatment, which is associated with reduced morbidity, mortality, and transmission of HIV (6). Findings from CDC's report on monitoring selected HIV prevention and care objectives indicate blacks have lower HIV linkage (71.6%) and viral suppression (48.5%) percentages than do whites (79.0% and 62.0%, respectively) (1).
Consistent with findings from a previous report on the continuum of HIV care among blacks with diagnosed HIV based on data from 19 jurisdictions, males had lower levels of care and viral suppression than did females, and persons aged <35 years had lower levels of viral suppression than did persons aged ≥35 years (7). The lowest levels of care and viral suppression among blacks with HIV in these 33 jurisdictions were among persons with infection attributed to IDU and males with infection attributed to heterosexual contact. Results of analyses by sex, and transmission category and age group should be interpreted with caution because some subpopulations have small numbers. In addition to routine testing for HIV to identify persons with unrecognized infection, interventions are needed to ensure that all persons with HIV receive optimal care; tailored strategies for black persons   who inject drugs, black youths, and black males who engage in heterosexual contact might be needed to achieve improvements in care outcomes. U.S. Department of Health and Human Services treatment guidelines recommend that all adults and adolescents living with HIV in the United States be offered treatment (2). The findings in this report are subject to at least two limitations. First, analyses were limited to 33 jurisdictions with complete laboratory reporting of all levels of CD4 and VL test results; these 33 jurisdictions might not be representative of all blacks living with diagnosed HIV infection in the United States. Second, comparisons of numbers and percentages by sex, and transmission category and age group should be made and projects that support linkage to, retention in, and return to care for all persons infected with HIV (9). Among blacks, tailored strategies for subpopulations, including persons who inject drugs and young males with infection attributed to heterosexual contact, might be needed to achieve the NHAS goal of 80% of persons living with diagnosed HIV having a suppressed viral load for all population segments.