Understanding HIV Incidence Trends and Prevention Strategies

June 21, 2023 - In May, the CDC released a report as a part of the Ending the HIV Epidemic (EHE) in the United States initiative analyzing the trends in HIV prevalence. The data reflects the benefits of prevention strategies; however, improvements also reflect inequities across different demographic groups.

“The CDC saw a 12% drop. Between 2017 and 2021, there has been a significant decline. But the thing is, it's not every group; it’s a particular group,” said Maranda Ward, EdD, MPH, assistant professor and Director of Equity in the Department of Clinical Research and Leadership at George Washington University, in an interview with LifeSciencesIntelligence.

LifeSciencesIntelligence sat down with Ward to discuss the data, disproportionate outcomes, and how to improve equity across the entire patient population.

HIV/AIDS

HIV, short for human immunodeficiency virus, is a viral infection that targets the immune system. The virus originated from a type of chimpanzee in Central Africa, making a zoonotic jump to humans around the late 1800s. Researchers postulate that HIV is a version of the simian immunodeficiency virus contracted through contact with infected blood from these animals during hunting.

Within four weeks of infection, some patients infected with HIV will begin exhibiting flu-like symptoms, including sore throat, swollen lymph nodes, rash, fever, muscle aches, night sweats, mouth ulcers, chills, and fatigue. However, many patients do not exhibit symptoms at all in the early stages of the disease.

The early stage of infection is often called the acute HIV infection phase, during which the viral load is extremely high, and patients are very contagious.

The second stage is chronic HIV infection, sometimes called asymptomatic or clinical latency. Although the virus is replicating and patients are still contagious, many patients may not even know they have it. This phase can last over a decade for some patients.

When the viral load reaches a high point, patients transition into the acquired immunodeficiency syndrome (AIDS) phase, with an average survival rate of three years.

The CDC National Prevention Information Network notes that the first reports of AIDS were in June 1981. Although the name AIDS was not coined until the following year, researchers noted that 42,000 people were living with HIV and 20,000 new HIV infections in 1981.

Four years later, in 1985, the first link was made between HIV and AIDS, noting that AIDS is caused by HIV infection. By that point, the number of people living with HIV had increased tenfold to 420,000.

HIV Risk

Despite common early misunderstandings, HIV transmission can only occur when HIV-infected patients share fluids that get into the bloodstream through mucus membranes, open cuts, or direct injection. HIV cannot be transmitted through contact with saliva, tears, or sweat, shaking hands, cutting, sharing utensils, swimming in the same pool, and insect bites.

According to the National Institute of Child Health and Human Development, a subset of the NIH, HIV risk increases with sexual activity, number of sexual partners, a history of sexually transmitted infections (STIs), and drug use.

Standard HIV Care and Prevention Tools

Even those in high-risk categories can prevent HIV acquisition and transmission through multiple tools. The CDC notes that there are numerous evidence-based strategies to prevent HIV infection and reduce transmission rates. One of the most critical strategies is condom use. As one of the only forms of birth control that can prevent STIs, condoms provide a physical barrier to prevent HIV transmission.

Another tool is pre-exposure prophylaxis (PrEP), a drug for HIV-negative individuals who may be at a higher risk of contracting HIV.

For those at an increased risk of HIV due to drug use, avoiding needle or syringe sharing can also be an excellent way to minimize risk.

Another vital tool to prevent HIV transmission is antiretroviral therapy (ART). This medication, prescribed by a licensed healthcare provider, can significantly reduce an HIV-positive patient’s viral load, making transmission less likely.

“Right now, there's a huge campaign that the CDC is doing called U equals U, which is undetectable HIV becomes untransmittable,” noted Ward.

HIV Prevalence in 2021

On May 23, 2023, the Centers for Disease Control and Prevention (CDC) published a report announcing a decline in HIV infections among young people and the general population. While the report suggests improved public health trends, there are some significant discrepancies in HIV prevention across different patient demographics.

The data was collected as a part of the EHE initiative launched by the US Department of Health and Human Services (HHS) in 2019. The initiative’s goals include a 75% reduction in new HIV diagnoses by 2025 and a 90% reduction by 2030.

The research used data from the National HIV Surveillance System (NHSS) on HIV incidence across all 50 states and Washington, DC.

Throughout her conversation with LifeSciencesIntelligence, Ward acknowledged that there is a gap when it comes to surveillance data. Researchers and clinicians collect the data, but it takes time to clean, analyze, and report on it, leading to a delay between collection and analysis.

The report estimated roughly 32,000 HIV cases in 2021, a significant decline from the 2017 incidence rate of approximately 36,000. Although a substantial reduction indicated effective prevention efforts, health disparities prove that access to these tools or the ability to use them is unequal.

Race and Ethnicity

Ward explained that the declining rates are predominantly attributed to one group.

“That group is White men who have sex with men,” she explained. “I'm being intentional in saying men who have sex with men (MSM) because not everyone identifies as being gay or bisexual, even though the behavior that they're engaging in being someone who identifies as a man who's having sex with a man. It's imperative to focus on the behavior and not, necessarily, the label.”

Ward explained that the 34% drop in HIV rates among White MSM represents roughly half of the overall decline in HIV rates, a critical finding. Although rates declined overall, racial and ethnic disparities were apparent in the data collected.

Most HIV incidences were Black individuals, which comprised 40% of infections in 2021. Hispanic and Latino individuals were the next largest categories, amounting to 29% of infections. White individuals made up 26% of cases. Additionally, multiracial, Asian, and American Indian/Alaska Native people comprised the remaining 5%.

Black and African American individuals comprise just 12% of the US population but form over triple the percentage of HIV incidences. Meanwhile, White people comprise 61% of the US population but only 28% of HIV incidences.

Across all Black and African American patients, male-to-male sexual contact (MMS) accounted for 62% of cases, while heterosexual contact was only 32%.

Black people were disproportionately affected by HIV, with their rates roughly seven times greater than White individuals.

Sex at Birth

The study looked at data from multiple perspectives. For example, one component looked at the differing rates based on assigned sex at birth, noting that those assigned males comprised 81% of infection, while those assigned females only accounted for 19%.

In those assigned males at birth, HIV prevalence declined, accounting for 18.8 thousand. However, the rate in those assigned females at birth remained stagnant, at 4.4 thousand.

Although the CDC report focused on assigned birth sex, a fact sheet published by HIV.gov notes that transgender women accounted for 2% of HIV cases in 2020, while transgender men accounted for 1%.

Transmission Categories

In addition, the CDC analyzed infection based on HIV transmission categories. MMS accounted for roughly two-thirds of the cases, at 66%. Meanwhile, heterosexual contact, injection drug use, and MMS with injection drug use made up 22%, 8%, and 4% of cases, respectively.

Age

The analysis also reviewed the HIV rates across varying age groups. For adolescents and young adults, rates decline from previous years. More specifically, the 13–24 age bracket declined while all other analyzed groups remained the same.

Sexuality

The report focused on groups known to have a high risk of HIV, including gay and bisexual men or other MSM.

The report notes, “Stigma, homophobia, and discrimination make MSM of all races/ethnicities susceptible to multiple physical and mental health problems and can affect whether they seek and receive high-quality health services, including HIV testing, treatment, and other prevention services.”

Knowledge of HIV Status

One component of the initiative is to improve knowledge of HIV status. If affected patients understand their status, there are interventions and HIV treatments, including antiretroviral therapy (ART), that can help induce viral suppression and minimize morbidity and mortality.

Additionally, knowledge of HIV status and adequate HIV care can act as a prevention strategy for reducing the transmission of HIV from positive patients to HIV-negative individuals.

Beyond the declining rates of HIV, patients’ knowledge of HIV status increased drastically. The data shows that 87% of HIV-positive patients knew their HIV status.

Although the CDC estimates that 1.2 million people in the United States have HIV, many are unaware of their status. Approximately one in eight people do not know they have HIV because of a lack of access to HIV screening or the stigma surrounding it acts as a barrier to getting screened.

“The CDC guidelines are that anybody between the ages of 13 and 64 should be asked at least once in their lifetime about an HIV test. So obviously, those need to be updated because risk doesn't work like that,” she noted.

A patient’s HIV risk is not the same at 13 and 64. A singular screening is not sufficient to properly assess a patient’s risk and need for follow-up testing.

Acknowledging Disparities

“There's no biological explanation for disparities. The only explanation is social because if we see that one entire subpopulation in the US has a decline, it's possible for other groups,” noted Ward.

Disparities in disease are not limited to HIV. Nearly every healthcare sector, including cancer care, has disparities across different patient demographics.

“The explanation is social,” asserted Ward. “It's uneven access to screening and care, which is directly related to discrimination, specifically heterosexism, racism, transphobia, and xenophobia.”

Bias and Stigma in HIV Care

“My team has a set of very robust policy recommendations for that, but also for PrEP screening and the like,” noted Ward.

However, she countered that a risk-based approach to testing or screening leaves the assessment to the provider’s discretion. For example, a provider whose patient has been married for 20 years may not think to screen them for HIV, despite knowing that marriage does not eliminate risk.

“There's age bias. There's marital status bias, all these different forms of bias,” added Ward. “Being married doesn't protect patients from HIV. Age does not protect you from HIV.”

“Researchers have been engaged in research where we talked to racial, ethnic, sexual, and gender-minoritized patients,” noted Ward. “They said that when a PCP asked them, ‘Would you want to get an HIV test today?’ they feel offended.”

“There is a stigma already attached to the term. So if providers can add, ‘this is a question we ask everybody,’ clinicians can remove the stigma.”

She compares it to mental health screenings providers implement across various patient populations. Instead of focusing exclusively on risk, mental health screenings have shifted to focus on health, not targeting specific “at-risk” populations. Ward recommends a similar approach to sexual health.

“This type of screening is not happening, which explains why only 11% of Black people are even offered PrEP, preexposure prophylaxis, the daily pill patients would take if they don't have HIV and may be exposed to it.”

Compared to 11% of Black people being prescribed PrEP, 20% of Hispanic and 78% of White people are prescribed the treatment.

“The only explanation is unfair, uneven, unnecessary, avoidable discrepancies and in offering it across the board,” added Ward.

“As a Black woman, I’m very alarmed when I read that Black people make up 13% of this country but are 40% of new cases. And Black women, specifically, make up 58% of new cases.”

The infection rates are double that of White women and triple that of Hispanic women.

Improving Prevention and Treatment Strategies

Ward’s own experience indicates an alarming strategy. She notes that she has never been asked for an HIV test, despite living in DC, an opt-out territory in the US. As an opt-out state, patients are tested for HIV unless they choose to opt-out.

“No one has ever told me, ‘Oh, by the way, we're going to go ahead and test for HIV, but let us know if you don't want to’ and then gave me the opportunity to have informed refusal,” she revealed. “But I know I'm getting tested for HIV because I see my LabCorp bill, which has HIV tests.”

Ward identifies a lack of informed refusal as a missed opportunity in healthcare.

“On the one hand, the fact that providers just automatically screen is a great approach so that it becomes automated. But ethically, we do need to inform patients,” she explained.

Discussing Safe Sex

“One of the things that public health experts are calling for is to normalize conversations on sex and to use sex-positive language, focusing on health and not risk,” added Ward. “Right now, the way that sex, HIV, and any other sexually transmitted infection is talked about in a healthcare setting is as a risk, something to prevent.”

Ward explains the importance of knowing your HIV status, as it can help patients get lifesaving treatments early on. She explains that although HIV is an infectious disease, medical innovation and research have made it a chronic condition that people can age with until they die of natural causes.

“When we say prevention, testing is prevention, and being on treatment is prevention. It's not just about preventing HIV. We do our best to prevent it, but we must recognize that some people will get HIV, so what will we do for them?”

Other Factors Impacting Health Outcomes

Beyond addressing screenings and providing access to treatment, it is crucial to understand the community-based factors that can impact treatment access.

“Roughly 80% of what determines our health outcomes is not healthcare access; it’s everything else. It's housing, the neighborhood, built environment, community safety, food, and everything else,” stressed Ward.

“From an advocacy perspective, we must think about what we call those social determinants of health.”

She explained that now multiple models allow clinicians to bill for the time they spend talking about the social determinants of health, including risk factors like food insecurity, unstable housing, or other sub-optimal conditions that may impact the uptake of or adherence to treatments. Allowing providers to bill for that time is one way to incentivize these conversations.

There is evidence that addressing these underlying determinants can significantly improve patient outcomes.

For example, Ward noted, “DC Health just did a pilot where Black MSM enrolled in a program where they gave all of them housing. They did a workforce development program and talked about financial literacy and other things.”

They found that the patients who were not on PrEP or started but did not continue were all taking PrEP after the study’s duration.

“All of them were on PrEP and regularly taking it, in addition to regularly seeing their PCP to get the blood draws and make sure to all the things for preventing HIV,” explained Ward.

The increased treatment retention rates highlight the importance of housing considerations in HIV/AIDS strategy. The last thing patients think about when they don’t know where to sleep is taking a pill.

Moving Forward

As efforts to develop an HIV vaccine, other prevention tools, and a cure continue, a multi-stakeholder approach to preventing, treating, and managing HIV transmission is critical.

“We offer a nine-part training series for PCPs, which is available in two forms. The online course is not yet accessible, but it will be in the future. Currently, we provide monthly one-hour recorded CME sessions that qualify for continuing medical education credit. To date, we have conducted five out of the nine planned sessions, with three of them focusing on what we refer to as culturally responsive communication.,” revealed Ward.

Providers, patients, and public health experts must take initiative and actionable steps toward reducing transmission.