Nicole Crepaz

This systematic review synthesized published literature (2000 – 2023) to identify HIV interventions specifically designed for transgender persons in the United States (PROSPERO registration number: CRD42021256460). The review also summarized strategies for improving outcomes related to the four pillars of the Ending the HIV Epidemic (EHE) initiative in the United States: Diagnose, Treat, Prevent, and Respond. A comprehensive search was conducted using the Centers for Disease Control and Prevention’s HIV Prevention Research Synthesis Project database, which included over 120,000 citations from routine systematic searches in CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts. Of 23 interventions that met inclusion criteria, 94% focused on transgender women of color and 22% focused on young transgender persons aged 15–29 years old. Most interventions focused on Treat or Prevent, few focused on Diagnosis, and none focused on Respond. Twenty interventions (87%) showed improvement in at least one EHE related outcome and a quarter of these effective interventions were tested with randomized controlled trials. Common strategies observed in effective interventions include the following: engaging the community in intervention development; pilot-testing with the focus population to ensure appropriateness and acceptability; addressing social determinants of health (e.g. stigma, discrimination, violence) through empowerment and gender-affirming approaches; increasing access to care, prevention, and services through co-location and one-stop shop models; and utilizing peer-led counseling, education, support, and navigation. Continuous effort is needed in addressing gaps, including more research for transgender men and rural settings and for how best to adopt and adapt best practices for subgroups of transgender population.

This systematic review synthesized published literature (January 2008-October 2021) about the association between social determinants of health (SDOH) and HIV testing among Hispanic/Latino gay, bisexual, and other men who have sex with men (HLMSM), a group disproportionally affected by HIV. Having higher education than a high school diploma, health insurance and access to health care services, and visiting a health care provider in the past 12 months were some of the determinants associated with HIV testing, while limited English proficiency was associated with reduced odds of HIV-testing among HLMSM. More research is needed to understand the relationship of SDOH (especially neighborhood) and HIV testing, how SDOH may affect HIV testing among different HLMSM groups, and how to increase self-testing and use of e-health in this priority population. Additionally, culturally and linguistically appropriate multilevel interventions and health services for HLMSM are urgently needed to diagnose HIV as early as possible after infection.

In the United States, Hispanic/Latino men who have sex with men (HLMSM) are disproportionally affected by HIV. We conducted a rapid review of national surveillance data to examine disparities in HIV prevention and care outcomes among HLMSM. Thirteen reports provided relevant data from 2011 to 2018. Compared to White MSM, a higher percentage of HIV-negative HLMSM reported not taking PrEP and engaging in condomless sex; a lower percentage of HIV-negative HLMSM at risk for HIV reported PrEP awareness and use; and a lower percentage of HIV-positive HLMSM were aware of their status, linked to HIV care, and virally suppressed. Viral suppression rates in HLMSM were better among Ryan White clients than the national rates, suggesting that access to comprehensive care/services reduces disparities. Findings also call for identifying individual, social, and structural factors contributing to condomless sex without PrEP use and HIV status unawareness and identifying best approaches for scaling up comprehensive care/services.

Objective: To examine changes in the lengths of time from HIV infection to diagnosis (Infx-to-Dx) and from diagnosis to first viral suppression (Dx-to-VS), two periods during which HIV can be transmitted. Design: Data from the National HIV Surveillance System (NHSS) for persons who were aged at least 13 years at the time of HIV diagnosis during 2014–2018 and resided in one of 33 United States jurisdictions with complete laboratory reporting. Methods: The date of HIV infection was estimated based on a CD4⁺-depletion model. Date of HIV diagnosis, and dates and results of first CD4⁺ test and first viral suppression (+ count at diagnosis. Conclusion: The shortened Infx-to-Dx and Dx-to-VS intervals suggest progress in promoting HIV testing and earlier treatment; however, diagnosis delays continue to be substantial. Further shortening both intervals and eliminating disparities are needed to achieve Ending the HIV Epidemic goals.

Background: Since 2012, treatment guidelines have recommended initiating antiretroviral therapy for all persons as soon as possible after HIV diagnosis, irrespective of CD4 counts. If clinicians adopted the treatment guidelines, a shortened interval between diagnosis and first viral suppression (Dx-to-VS) would be expected, with greater declines among those with CD4 counts ≥500 cells/µL at diagnosis. Methods: Using the National HIV Surveillance System data, we examined Dx-to-VS intervals among persons aged ≥13 years with HIV infection diagnosed during 2012–2017. Analyses were stratified by the first CD4 count: CD4 ≥500 cells/µL, 200–499 cells/µL, P < 0.001) and in all CD4 groups. In 2012, the Dx-to-VS interval was longer for persons with CD4 ≥500 cells/µL than 200–499 cells/µL and <200 cells/µL (median, 9, 7, and 6 months, respectively). By 2017, the median interval was 4 months for these groups, compared with 25 months for those without a CD4 value within 3 months after diagnosis. Conclusion: Decreases in Dx-to-VS intervals across all CD4 groups with a greater decrease among those with CD4 ≥500 cells/µL are consistent with the implementation of treatment recommendations. The Dx-to-VS interval was longest among persons not linked to care within 3 months after diagnosis, underscoring the importance of addressing barriers to linkage to care for ending the HIV epidemic.

Background: In 2016, persons aged 13–29 years represented 23.1% of the US population, yet accounted for 41.7% of HIV diagnoses. Racial/ethnic minorities are disproportionally affected by HIV. Sustaining viral suppression helps persons living with diagnosed HIV infection (PLWDH) stay healthy and reduces the risk of transmitting HIV. We examined racial/ethnic disparities in sustained viral suppression and transmission risk potential among PLWDH aged 13–29 years. Methods: We analyzed data from the National HIV Surveillance System reported through December 2018 from 42 jurisdictions with complete laboratory reporting. We included persons aged 13–29 years who received an HIV diagnosis by December 31, 2015, most recently resided in one of the 42 jurisdictions, and were alive at the end of 2016. Sustained viral suppression was defined as viral load 1500 copies/mL. Results: Of the 90,812 PLWDH aged 13–29 years included in the analysis, 41.5% had sustained viral suppression in 2016. Across age, sex, and most transmission categories, blacks had the lowest prevalence of sustained viral suppression. Among the 28,154 who were in care but without sustained viral suppression, the average number of days with viral load >1500 copies/mL was 206 days (56.4% of the 12-month period). Conclusions: Sustained viral suppression was suboptimal and transmission risk potential was high for PLWDH aged 13–29 years. Racial/ethnic disparities were apparent, calling for strengthening tailored interventions to improve care outcomes.

Background: Calculating national rates of HIV diagnosis, incidence, and prevalence can quantify disease burden, and is important for planning and evaluating programs. We calculated HIV rates among MSM, persons who inject drugs (PWID), and heterosexuals in 2010 and 2015. Methods: We used proportion estimates of the US population classified as MSM, PWID, and heterosexuals along with census data to calculate the population sizes which were used as the denominators for calculating HIV rates. The numerators (HIV diagnosis, incidence, and prevalence) were based on data submitted to the National HIV Surveillance System through June 2017. Results: The estimated HIV diagnosis and incidence rates in 2015 were 574.7 and 583.6 per 100 000 MSM; 34.3 and 32.7 per 100 000 PWID; and 4.1 and 3.8 per 100 000 heterosexuals. The estimated HIV prevalence in 2015 was 12 372.9 per 100 000 MSM; 1937.2 per 100 000 PWID; and 126.7 per 100 000 heterosexuals. The HIV diagnosis rates decreased from 2010 to 2015 in all three transmission categories. Black individuals had the highest HIV diagnosis rates at both time points. The HIV incidence rates decreased among white MSM, MSM aged 13–24 years, PWID overall, and male and female heterosexual individuals; however, it increased among MSM aged 25–34 years. Conclusions: The estimated HIV diagnosis and HIV infection rates decreased for several transmission categories, and also race/ethnicity and age subgroups. MSM continue to be disproportionately affected. Disparities remain and have widened for some groups. Efforts are needed to strengthen prevention, care, and supportive services for all persons with HIV infection.

Fewer blacks with diagnosed HIV infection had sustained viral suppression in 2014 than Hispanics or whites.

Objective: To examine changes in viral suppression status among HIV patients receiving care in 2014 and the extent of viral suppression among persons with infrequent care visits. Methods: Using data reported to the National HIV Surveillance System from 33 jurisdictions with complete reporting of CD4⁺ and viral load tests, we created four viral suppression status groups based on their first and last viral loads in 2014: both suppressed, first unsuppressed and last suppressed (improved), first suppressed and last unsuppressed (worsened), and both unsuppressed. We also calculated the number and percentage of persons whose sole viral load in 2014 was suppressed and had a suppressed viral load at their last test in 2013. Results: Among 339 515 persons with at least two viral load tests in 2014, 72.6% had all viral loads suppressed (durably suppressed); 75.5% had the first and last tests suppressed, 10.5% improved, 4.2% worsened, and 9.9% had both unsuppressed. Among 92 309 persons who had only one viral load test in 2014, 69 960 (75.8%) were suppressed and, of those, 53 834 (76.9%) also had a suppressed viral load at their last test in 2013. Conclusion: National surveillance data show that the majority of patients in HIV care during 2014 were durably suppressed. More showed improved compared with worsened viral suppression status. Some patients who have less frequent care visits have sustained viral suppression. Yet one in 10 who was in regular care did not have a suppressed viral load in 2014, indicating missed opportunities for clinical interventions to help patients achieve and sustain viral suppression.