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Time to HIV Diagnosis Falling in US,
But Half With HIV Undiagnosed After 3 Years
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AIDS 2020: 23rd International AIDS Conference Virtual, July 6-10, 2020
Mark Mascolini
Estimated time from HIV infection to diagnosis dwindled among adults and adolescents in the United States from 2014 to 2018, mostly because of improvements in high-prevalence southern and western states [1]. But this Centers for Disease Control and Prevention (CDC) analysis found that half of HIV-infected people in the United States still went undiagnosed for 3.25 years in 2018.
CDC investigators who conducted this study noted that diagnosing HIV as soon as possible is critical to ending the epidemic. In the United States, for example, people with undiagnosed HIV account for 38% of all transmissions [2]. The CDC team aimed to estimate the interval between HIV infection and diagnosis (1) nationally from 2014 through 2018 and (2) by age at diagnosis, race/ethnicity, sex, HIV transmission category, and region.
Data came from the CDC's National HIV Surveillance System in 50 US states and Washington, DC. The analysis included people 13 or older when diagnosed with HIV from 2014 through 2018. Researchers figured the date of HIV infection by the CD4-depletion model [3]. Date of diagnosis came from data reported to the CDC.
The analysis included 195,052 HIV diagnoses, from about 37,000 to 40,000 in each of the 5 study years (2014-2018). Over that span median time to HIV diagnosis improved from 43 months to 39 months for an estimated annual percentage change of -2.0% (95% confidence interval -2.6 to -1.5, P < 0.001).
Over those years estimated median months to diagnosis fell significantly in people 55 and older (-3.8%), people 35 to 44 (-5.4%), and people 25 to 34 (-1.2%) (P < 0.05 for all). Months to diagnosis also dwindled in the other two age groups (45 to 54 and 13 to 24) but not significantly. But in 2018 the lag between infection and diagnosis remained higher in older people (median 58 months in the 55+ group and 56 months in 45-to-54-year-olds, compared with 43 months at ages 35-44, 33 months at ages 25-34, and 32 months at ages 13-24).
By race or ethnicity, blacks had the biggest percentage drop in estimated months to diagnosis (45 to 41 months, -2.5%), followed by Hispanics (46 to 42 months, -1.8%) (P < 0.05 for both). Estimated months to diagnosis dipped from 34 to 33 in whites (-1.0%), a nonsignificant change. But in 2018 estimated months to diagnosis lay much lower in whites (33 months) than in Hispanics (42 months) or blacks (41 months).
By HIV transmission category, three male groups had significant 2014-2018 declines in estimated months to HIV diagnosis: -13.1% in injection drug users, -3.6% in men who have sex with men (MSM) and inject drugs, and -2.6% in heterosexuals. Among women, months to diagnosis fell significantly for heterosexuals (-7.1%) and injection drug users (-4.9%) (P < 0.05 for all changes). But among males in 2018 heterosexuals had by far the longest estimated delay in HIV diagnosis (65 months) compared with MSM (41) or injection drug users (35).
Regionally, the biggest drops in months to HIV diagnoses came in the South (-3.0%) and the West (-1.3%) (P < 0.05), which account for 71% of HIV diagnoses in the United States. Estimated drops were smaller and nonsignificant in the Northeast (-0.8%) and the Midwest (-0.1%). By 2018 the four regions did not differ substantially in estimated months to diagnosis (range 36 to 44). States with the lowest estimated range of months to HIV diagnosis in 2018 (23 to 35) were California, Nevada, Utah, Oklahoma, Iowa, Louisiana, Kentucky, Florida, and Massachusetts.
The CDC team cautioned that their analysis rests on the assumptions that the CD4-depletion model [3] is correct in assigning date of HIV infection and that infected people went untreated for HIV infection before their first CD4 count. The investigators stressed that "delayed HIV diagnoses continue to be substantial in 2018," with 1 in 2 people carrying HIV for 3.25 years before diagnosis. They believe their findings "show disparities and areas that need innovative strategies to address barriers to HIV testing and early diagnosis."
References
1. Crepaz N, Song R, Lyss S, et al. Estimated time from HIV infection to diagnosis, 50 U.S. states and the District of Columbia, 2014-2018. AIDS 2020: 23rd International AIDS Conference Virtual. July 6-10, 2020. Abstract OAC0206.
2. Li Z, Purcell DW, Sansom SL, Hayes D, Hall HI. Vital Signs: HIV transmission along the continuum of care--United States, 2016. MMWR Morb Mortal Wkly Rep. 2019 Mar 22;68(11):267-272. https://www.cdc.gov/mmwr/volumes/68/wr/mm6811e1.htm
3. Song R, Hall HI, Green TA, Szwarcwald CL, Pantazis N. Using CD4 data to estimate HIV incidence, prevalence, and percent of undiagnosed infections in the United States. J Acquir Immune Defic Syndr. 2017;74:3-9. doi: 10.1097/QAI.0000000000001151.
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