HIV Testing Outcomes Among Blacks or African Americans — 50 Local U.S. Jurisdictions Accounting for the Majority of New HIV Diagnoses and Seven States with Disproportionate Occurrences of HIV in Rural Areas, 2017

Identifying persons with human immunodeficiency virus (HIV) infection who are unaware of their status and linking them to care are critical steps in achieving viral suppression and reducing the risk for transmitting HIV (1). In 2017, 43% of new diagnoses of HIV infection were among persons who self-identify as blacks or African Americans (blacks) (2), who represent 13% of the U.S. population (3). Fewer blacks, compared with whites, were linked to HIV medical care within 90 days of diagnosis, retained in care, or virally suppressed (4). Ending the HIV Epidemic (EHE) is an initiative intended to reduce new HIV infections by 90% from 2020 to 2030 (5). EHE’s Phase 1 is focused on 50 jurisdictions* that accounted for >50% of new diagnoses during 2016–2017 and seven states^† with disproportionate HIV prevalence in rural areas (5). The purpose of this analysis was to examine HIV testing outcomes among blacks in high prevalence EHE jurisdictions, using CDC’s 2017 National HIV Prevention Program Monitoring and Evaluation data. Blacks accounted for 43.2% of CDC-funded tests and 49.1% of new diagnoses of HIV infection. Seventy-nine percent of blacks with newly diagnosed HIV infection were linked to HIV medical care within 90 days (below the 2010 National HIV/AIDS Strategy goal of 85%), 71.4% interviewed for partner services, and 81.8% referred to prevention services. To achieve the goals of EHE, HIV prevention programs should focus on locally tailored evidence-based^§ testing strategies to enhance and overcome barriers for linkage to and retention in care and reduce onward HIV transmission and HIV-related disparities.

CDC analyzed 2017 HIV testing, linkage to care, and partner services data submitted to the National HIV Prevention Program Monitoring and Evaluation system by 61 CDC-funded health departments^¶ and 150 CDC-directly funded community-based organizations. Valid HIV tests were those with confirmed HIV-positive test results (discordant and indeterminate test results were excluded). Persons with new diagnoses were those whose HIV test results were positive during the current test and were not previously reported in the health department’s HIV surveillance system or had reported not having had a previous HIV-positive test result. The percentage of positive tests (positivity) for new diagnoses was calculated by dividing the number of new HIV-positive tests by the number of valid tests. Data were stratified by age, gender, race/ethnicity, test setting, U.S. census region, and subpopulation (i.e., men who have sex with men [MSM], persons who inject drugs, heterosexual men, and heterosexual women).** In non–health care settings, data to identify subpopulations were required for all tests conducted; in health care settings data were required only for persons with HIV-positive test results. Subpopulation data included in the analysis were only from non–health care settings.^†† The following HIV testing outcomes were analyzed among blacks with newly diagnosed HIV infection: linkage to HIV medical care (e.g., attend first medical appointment) within 90 days of positive test result; interview for partner services (i.e., soliciting information from persons with HIV-positive test results regarding sex and drug-injecting partners to notify them of potential exposure and offer services); and referral to HIV prevention services (i.e., behavioral interventions and risk-reduction counseling). Percentages of HIV testing outcomes among blacks were calculated by dividing the number in which “yes” was indicated for the HIV testing outcomes (linked to care within 90 days, interviewed for partner services, and referred to prevention services) by the number of HIV-positive tests. Missing data were excluded from all outcome denominators. SAS (version 9.4; SAS Institute) was used to conduct all analyses.

During 2017, a total of 3,110,049 CDC-funded tests were conducted in the United States, including 1,954,741 (62.9%) in Phase-1 jurisdictions (Table 1). The highest percentages of HIV tests conducted in EHE Phase-1 jurisdictions were among persons aged 20–29 years (36.0%), males (52.3%), and those residing in the South Census region (57.0%). Blacks accounted for 43.2% (844,819) of tests conducted in Phase-1 jurisdictions, twice that of whites (21.6%; 421,656) or Hispanics/Latinos (22.4%; 437,635). Among all new HIV diagnoses, 68.9% (8,154 of 11,843) occurred in Phase-1 jurisdictions, and the highest percentages of new HIV diagnoses were among persons aged 20–29 years (42.9%), males (83.4%), blacks (49.1%), and persons residing in the South Census region (49.1%). The percentage of blacks with newly diagnosed HIV infection (0.5%) was equal to that of Hispanics/Latinos (0.5%) and nearly twice that of whites (0.3%) and Asians (0.3%).

In 2017 CDC-funded testing programs identified 11,427 persons with a previous diagnosis of HIV infection who were not known to be in care, 8,917 (78.0%) of whom were in Phase-1 jurisdictions. Persons with a previous diagnosis who were not known to be in care were predominately aged 20–29 years (30.2%) or 30–39 years (27.7%), male (78.1%), black (58.5%), and residents of the South Census region (62.0%). The number of blacks in Phase-1 jurisdictions with a previous diagnosis and not known to be in care (5,214; 58.5%) was more than three times that of whites (1,516; 17.0%) and Hispanics/Latinos (1,359; 15.2%).

Among the 844,819 blacks tested in Phase-1 jurisdictions in 2017, 37.7% (318,835) were persons aged 20–29 years; 49.7% were males; and 63.2% were persons residing in the South (Table 2). Of the 4,007 blacks who received a new diagnosis of HIV infection, the percentage positivity was highest among persons aged 20–29 years (0.6%), males (0.7%), and persons residing in the West Census region (0.7%). Among blacks who received a new diagnosis, 79.2% were linked to care within 90 days, 71.4% were interviewed for partner services, and 81.8% were referred to HIV prevention services. By region, linkage of blacks with newly diagnosed HIV infection to medical care within 90 days was lowest in the West (71.7%), whereas the lowest percentages of partner services interviews (58.9%) and referrals to HIV prevention services (70.2%) were in the Midwest. By subpopulation, the highest percentage of tests conducted in EHE jurisdictions were among MSM (27.4%) (Table 1), who also had the highest rates of HIV-positive test results (3.3%) among subpopulation blacks (Table 2).

Black MSM accounted for 15.0% (31,508 of 209,843) of tests and 64.9% (1,030 of 1,587) of new HIV diagnoses in non–health care settings. More than 70% of black MSM with newly diagnosed HIV infection were linked to HIV medical care (80.6%), interviewed for partner services (71.3%), or referred to HIV prevention services (84.2%) (Table 2).

Acknowledgments

Lisa Belcher, PhD, Janet Heitgerd, PhD, Program Evaluation Branch, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; John Brooks, MD, Office of the Director, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

Corresponding author: Aba D. Essuon, aee9@cdc.gov, 404-718-8712.

¹Program Evaluation Branch, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; ²Northrop Grumman, Falls Church, Virginia.

References

1. CDC. CDC’s role in ending the HIV epidemic: a plan for America. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. https://www.cdc.gov/endhiv/docs/CDC-role-ending-HIV-508.pdfpdf icon
2. CDC. Diagnoses of HIV infection in the United States and dependent areas, 2017. HIV surveillance report, vol. 30. Atlanta, GA: US Department of Health and Human Services, CDC; 2018. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2017-vol-29.pdfpdf icon
3. CDC. HIV and African Americans. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. https://www.cdc.gov/hiv/group/racialethnic/africanamericans/index.html
4. CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2017. HIV surveillance supplemental report, vol. 24. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-24-3.pdfpdf icon
5. Pitasi MA, Delaney KP, Brooks JT, DiNenno EA, Johnson SD, Prejean J. HIV testing in 50 local jurisdictions accounting for the majority of new HIV diagnoses and seven states with disproportionate occurrence of HIV in rural areas, 2016–2017. MMWR Morb Mortal Wkly Rep 2019;68:561–7. CrossRefexternal icon PubMedexternal icon
6. CDC. HIV in the southern United States. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://www.cdc.gov/hiv/pdf/policies/cdc-hiv-in-the-south-issue-brief.pdfpdf icon
7. Office of National AIDS Policy. National HIV/AIDS strategy for the United States: updated to 2020. Washington, DC: Office of National AIDS Policy; 2015. https://files.hiv.gov/s3fs-public/nhas-update.pdfpdf iconexternal icon
8. Seth P, Wang G, Belcher L. Previously diagnosed HIV-positive persons: the role of Centers for Disease Control and Prevention–funded HIV testing programs in addressing their needs. Sex Transm Dis 2018;45:377–81. CrossRefexternal icon PubMedexternal icon

Abbreviations: AI/AN = American Indian or Alaska Native; Col = column; H/PI = Native Hawaiian or Pacific Islander; MSM = gay, bisexual, and other men who have sex with men.
* Fifty local jurisdictions accounting for >50% of new diagnoses during 2016–2017 and seven states with disproportionate occurrence of HIV in rural areas.
^† For age, the numbers of records missing or invalid are as follows: in the columns “Valid CDC-funded HIV tests,” 35,414 (1.1%) of all CDC-funded valid HIV tests and 15,819 (0.8%) of valid HIV tests in EHE jurisdictions; in the columns under “New HIV diagnoses,” 44 (0.4%) of total new diagnoses and 33 (0.4%) of new diagnoses in EHE jurisdictions; in the columns under “Previous HIV diagnoses,” 14 (0.1%) of total previous diagnoses and 12 (0.1%) of previous diagnoses in EHE jurisdictions.
^§ For gender, the numbers of records reported as transgender, missing, or invalid are as follows: in the columns under “Valid CDC-funded HIV tests,” 36,163 (1.2%) of all CDC-funded valid HIV tests and 26,556 (1.4%) of valid HIV tests in EHE jurisdictions; in the columns under “New HIV diagnoses,” 245 (2.1%) of total new diagnoses and 185 (2.3%) of new diagnoses in EHE jurisdictions; in the columns under “Previous HIV diagnoses,” 241 (2.1%) of total previous diagnoses and 206 (2.3%) of previous diagnoses in EHE jurisdictions.
^¶ 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.
** For race/ethnicity, the numbers of records missing or invalid are as follows: in the columns under “Valid CDC-funded HIV tests,” 235,281 (7.6%) of all CDC-funded valid HIV tests and 173,373 (8.9%) of valid HIV tests in EHE jurisdictions; in the columns under “New HIV diagnoses,” 486 (4.1%) of total new diagnoses and 399 (4.9%) of new diagnoses in EHE jurisdictions; in the columns under “Previous HIV diagnoses,” 745 (6.5%) of total previous diagnoses and 629 (7.1%) of previous diagnoses in EHE jurisdictions.
^†† MSM include males who reported male-to-male sexual contact as well as males who reported both male-to-male sexual contact and injection drug use in the past 12 months. Persons who inject drugs include persons who reported injection drug use in the past 12 months. Heterosexual males include males who only reported sexual contact with a female in the past 12 months. Heterosexual females include females who only reported sexual contact with a male in the past 12 months. Data on subpopulations were limited to those tested in non–health care settings. For subpopulation in non–health care settings, the numbers of records missing or invalid are as follows: in the columns under “Valid CDC-funded HIV tests,” 129,466 (18.2%) of all CDC-funded valid HIV tests and 96,519 (21.4%) of valid HIV tests in EHE jurisdictions; in the columns under “New HIV diagnoses,” 291 (6.4%) of total new diagnoses and 210 (6.4%) of new diagnoses in EHE jurisdictions; in the columns under “Previous HIV diagnoses,” 483 (15.8%) of total previous diagnoses and 319 (14.8%) of previous diagnoses in EHE jurisdictions. Totals for subpopulation in non–health care settings are 712,278 for all CDC-funded HIV tests, 451,247 for CDC-funded tests in EHE jurisdictions, 4,539 for total new HIV diagnoses, 3,290 for new diagnoses in EHE jurisdictions, 3,050 for previously diagnosed, and 2,159 for previously diagnosed in EHE jurisdictions.

Abbreviation: MSM = gay, bisexual, and other men who have sex with men.
* Fifty local jurisdictions accounting for >50% of new diagnoses during 2016–2017 and seven states with disproportionate occurrence of HIV in rural areas.
^† For age, the numbers of records missing or invalid are as follows: in the column “CDC-funded tests among blacks in EHE jurisdictions,” 3,714 (0.4%); in the column “New HIV diagnoses among blacks in EHE jurisdictions,” 12 (0.3%); in the column “Linked to HIV medical care within 90 days of diagnoses,” 2 (0.1%); in the column “Interviewed for partner services,” 1 (0.05%); in the column “Referred to HIV prevention services,” 2 (0.1%).
^§ For gender, the numbers of records reported as transgender, missing, or invalid are as follows: in the column “CDC-funded tests among blacks in EHE jurisdictions,” 4870 (0.6%); in the column “New HIV diagnoses among blacks in EHE jurisdictions,” 98 (2.4%); in the column “Linked to HIV medical care within 90 days of diagnoses,” 68 (2.6%); in the column “Interviewed for partner services,” 52 (2.5%); in the column “Referred to HIV prevention services,” 70 (2.6%).
^¶ 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.
** MSM include males who reported male-to-male sexual contact as well as males who reported both male-to-male sexual contact and injection drug use in the past 12 months. Persons who inject drugs include persons who reported injection drug use in the past 12 months. Heterosexual males include males who only reported heterosexual contact with a female in the past 12 months. Heterosexual females include females who only reported heterosexual contact with a male in the past 12 months. Data on behavioral risk factors used to define the subpopulation were limited to those tested in non–health care settings. For subpopulation in non–health care settings, the numbers of records missing or invalid are as follows: in the column “CDC-funded tests among blacks in EHE jurisdictions,” 52,396 (25.0%); in the column “New HIV diagnoses among blacks in EHE jurisdictions,” 104 (6.6%); in the column “Linked to HIV medical care within 90 Days of diagnoses,” 47 (4.8%); in the column “Interviewed for partner services,” 39 (5.2%); in the column “Referred to HIV prevention services,” 60 (5.3%). Totals for subpopulation in non–health care settings are 209,843 for CDC-funded tests among blacks in EHE jurisdictions, 1,587 for new diagnoses among blacks in EHE jurisdictions, 980 for linked to HIV medical care within 90 days of diagnoses, 749 for interviewed for partner services, and 1,139 for referred to HIV prevention services.