Care Outcomes Among Black or African American Persons with Diagnosed HIV in Rural, Urban, and Metropolitan Statistical Areas — 42 U.S. Jurisdictions, 2018

During 2018, Black or African American (Black) persons accounted for 43% of all diagnoses of human immunodeficiency virus (HIV) infection in the United States (1). Among Black persons with diagnosed HIV infection in 41 states and the District of Columbia for whom complete laboratory reporting* was available, the percentages of Black persons linked to care within 1 month of diagnosis (77.1%) and with viral suppression within 6 months of diagnosis (62.9%) during 2018 were lower than the Ending the HIV Epidemic initiative objectives of 95% for linkage to care and viral suppression goals (2). Access to HIV-related care and treatment services varies by residence area (3-5). Identifying urban-rural differences in HIV care outcomes is crucial for addressing HIV-related disparities among Black persons with HIV infection. CDC used National HIV Surveillance System† (NHSS) data to describe HIV care outcomes among Black persons with diagnosed HIV infection during 2018 by population area of residence§ (area). During 2018, Black persons in rural areas received a higher percentage of late-stage diagnoses (25.2%) than did those in urban (21.9%) and metropolitan (19.0%) areas. Linkage to care within 1 month of diagnosis was similar across all areas, whereas viral suppression within 6 months of diagnosis was highest in metropolitan areas (63.8%). The Ending the HIV Epidemic initiative supports scalable, coordinated, and innovative efforts to increase HIV diagnosis, treatment, and prevention among populations disproportionately affected by or who are at higher risk for HIV infection (6), especially during syndemics (e.g. with coronavirus disease 2019).

care within 1 month of diagnosis was similar across all areas, whereas viral suppression within 6 months of diagnosis was highest in metropolitan areas (63.8%). The Ending the HIV Epidemic initiative supports scalable, coordinated, and innovative efforts to increase HIV diagnosis, treatment, and prevention among populations disproportionately affected by or who are at higher risk for HIV infection (6), especially during syndemics (e.g. with coronavirus disease 2019).
CDC analyzed data reported to NHSS for Black persons aged ≥13 years who received a diagnosis of HIV during 2018 in 41 states ¶ and the District of Columbia, jurisdictions in which laboratory reporting was complete as of December 31, 2019. Stage of disease** at diagnosis was classified using the 2014 surveillance case definition for HIV infection based on age-specific CD4 counts or percentages of total lymphocytes (2,7). Linkage to care within 1 month of diagnosis was measured by documentation of one or more CD4 counts or percentage of viral load test results within 1 month after diagnosis. Viral suppression within 6 months of HIV diagnosis was defined as a viral load of <200 HIV RNA copies/mL within 6 months of HIV diagnosis. Data were statistically adjusted by using multiple imputation techniques to account for missing HIV transmission categories (8). Analyses were conducted using SAS (   ¶ Transgender includes persons who identified as transgender male-to-female, transgender female-to-male, and additional gender identity. Data not displayed because the numbers were too small to be meaningful. "Transgender male-to-female" includes persons who were assigned "male" sex at birth but have ever identified as "female" gender. "Transgender female-to-male" includes persons who were assigned "female" sex at birth but have ever identified as "male" gender. Additional gender identity examples include "bigender, " "gender queer, " and "two-spirit. " ** Data have been statistically adjusted to account for missing transmission category; therefore, values might not sum to column subtotals and total. Data presented based on sex at birth and include transgender persons. † † Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. § § 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.
Males aged 45-54 years in rural and urban areas with infection attributed to heterosexual contact (rural: 69.9%, urban: 67.1%) and males aged 13-24 years in metropolitan areas with infection attributed to heterosexual contact (62.3%) accounted for the lowest percentage of being linked to care compared with persons with other modes of transmission in those areas.
Overall, the percentage of Black persons aged ≥13 years in rural areas with HIV diagnosed during 2018 who had <200 copies of viral RNA per mL (viral suppression) within 6 months of diagnosis was 59.6% in rural areas, 59.7% in urban areas, and 63.8% in metropolitan areas (Table 3) (Supplementary Figure, https://stacks.cdc.gov/view/cdc/102576). The percentage of males with viral suppression within 6 months of diagnosis was lower than the percentage among females, regardless of area (males, rural: 58.0%, urban: 57.8%, metropolitan: 62.4%; females, rural: 64.0%, urban: 65.1%, metropolitan: 68.1%). By age group and area, the lowest percentage of viral suppression within 6 months of diagnosis was among persons aged 45-54 years in rural and urban areas (52.1% and 56.4%, respectively) and persons aged 13-34 years in metropolitan areas (62.6%). In rural and urban areas, the lowest percentage of viral suppression within 6 months of diagnosis was among males aged 45-54 years with infection attributed to maleto-male sexual contact and to heterosexual contact (44.2% and 42.5%, respectively). In metropolitan areas, the lowest percentage of viral suppression within 6 months of diagnosis was among males aged 13-24 years with infection attributed to heterosexual contact (51.7%) and males aged 25-34 years with infection attributed to injection drug use (IDU) (45.0%).

Discussion
During 2018, one in four (25.2%) diagnosed HIV infections among Black persons in rural areas was a late-stage diagnosis, a percentage that was higher than that among Black persons in urban (21.9%) and metropolitan (19.0%) areas. The percentages of patients linked to care within 1 month of diagnosis were similar in all areas, whereas the percentages of persons with viral suppression within 6 months of diagnosis were lower in rural (59.6%) and urban (59.7%) areas than in metropolitan areas (63.8%). In all areas, the percentages of persons who were linked to care within 1 month of diagnosis and who had viral suppression within 6 months of diagnosis were substantially below the Ending the HIV Epidemic initiative targets of 95% (9). These findings likely underscore known differences in health-related behaviors, physical and sociocultural environments, and access to and use of health care systems among Black urban and rural HIV populations (3,4). Transgender includes persons who identified as transgender male-to-female, transgender female-to-male, and additional gender identity. Data not displayed because the numbers were too small to be meaningful. "Transgender male-to-female" includes persons who were assigned "male" sex at birth but have ever identified as "female" gender. "Transgender female-to-male" includes persons who were assigned "female" sex at birth but have ever identified as "male" gender. Additional gender identity examples include "bigender, " "gender queer, " and "two-spirit. " § Data have been statistically adjusted to account for missing transmission category; therefore, values might not sum to column subtotals and total. Data presented based on sex at birth and include transgender persons. ¶ Heterosexual contact with a person known to have, or to be at high risk for, HIV infection. ** Includes persons whose infection was attributed to hemophilia, blood transfusion, perinatal exposure, or whose risk factor was not reported or not identified. Data not displayed because the numbers were too small to be meaningful. Data not provided for states and associated counties that do not have laws requiring reporting of all CD4 and VLs, 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. † Transgender includes persons who identified as transgender male-to-female, transgender female-to-male, and additional gender identity. Data not displayed because the numbers were too small to be meaningful. "Transgender male-to-female" includes persons who were assigned "male" sex at birth but have ever identified as "female" gender. "Transgender female-to-male" includes persons who were assigned "female" sex at birth but have ever identified as "male" gender. Additional gender identity examples include "bigender, " "gender queer, " and "two-spirit. " § Data have been statistically adjusted to account for missing transmission category; therefore, values might not sum to column subtotals and total. Data presented based on sex at birth and include transgender persons. ¶ Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
By transmission category, the highest percentages of late-stage diagnoses in all areas were among males with infection attributed to heterosexual contact. The lowest levels of linkage to care within 1 month of diagnosis were among males in rural areas with infection attributed to both male-to-male sexual contact and IDU, and males in urban areas with infection attributed to IDU. Viral suppression within 6 months of diagnosis was least common in all areas among males aged ≥13 years with infection attributed to IDU. Broader implementation of routine HIV testing is needed to identify persons with undiagnosed infections and to initiate early treatment, particularly among older persons. Interventions that support patient retention and re-engagement in HIV care are necessary to improve care outcomes and reduce HIV transmission. Locally tailored strategies among Black persons who inject drugs and sexually active adults at higher risk for HIV infection should be implemented for effective prevention in both urban and rural areas.
The findings in this report are subject to at least three limitations. First, analyses were limited to the 42 jurisdictions with complete laboratory reporting; these jurisdictions might not be representative of all Black persons living with diagnosed HIV infection in the United States. Second, CD4 and viral load test results reported to HIV surveillance programs were used for determining stage of disease and monitoring linkage to care and viral suppression; CD4 and viral load laboratory tests might not have been obtained at all care visits. Not having these tests performed among patients in care or unreported to surveillance systems limits the ability to monitor care outcomes. Finally, comparisons of numbers and percentages by area, sex, age group, and transmission category should be made cautiously because population subgroups vary in size and some have small numbers. Reported numbers ≤12 and their accompanying percentages are not discussed.
Early HIV diagnosis and treatment among Black persons with HIV infection are necessary to reduce disparities and achieve national prevention goals. For equitable health to be achieved for Black persons in all geographic areas, culturally appropriate and stigma-free sexual health care is needed, particularly among those who live in rural communities. Although 80% of Black persons with diagnosed HIV live in metropolitan areas, identifying geographic disparities is important to ensure HIV-related health equity. Disparities in care outcomes should be addressed and interventions prioritized that address social determinants of health. † † Corresponding author: Shacara Johnson Lyons, SJohnsonLyons@cdc.gov, 404-718-1149. 1 Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; 2 ICF, Atlanta, Georgia. † † https://www.cdc.gov/socialdeterminants/docs/sdh-white-paper-2010.pdf

Summary
What is already known about this topic? Disparities in HIV care outcomes exist for Black persons with diagnosed human immunodeficiency virus (HIV) infection, and access to care and treatment services varies by residence area.
What is added by this report?
During 2018, rural Black persons received a higher percentage of late-stage HIV diagnosis (25.2%) than did those in urban (21.9%) and metropolitan areas (19.0%). Linkage to care within 1 month of diagnosis was similar across geographic areas; however, viral suppression within 6 months of diagnosis was highest in metropolitan areas (63.8%).
What are the implications for public health practice?
Early diagnosis and prompt treatment of Black persons with HIV infection, especially in rural areas, are necessary to reduce disparities in HIV care outcomes.