An 18 Percent Decline In U.S. HIV Incidence Over Six Years Is Not Enough

The National HIV/AIDS Strategy set forth in 2010 called for a 25 percent reduction in HIV incidence by 2015.

March 7, 2017 • By David Holtgrave and Robert Bonacci 

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On February 14, 2017, the U.S. Centers for Disease Control and Prevention (CDC) unveiled new HIV incidence estimates for the United States from the years 2008 through 2014. Employing a recently developed method for estimating HIV incidence (based on diagnostic and CD4 cell level at time of diagnosis information), CDC provided the first official updates of HIV incidence estimates in several years.

This new methodology and updated estimates are very welcome and will better help address the epidemic in the United States, since timely incidence estimates (previous estimates were for the year 2010) are key to understanding the dynamics of the U.S. epidemic and are an essential component to any national statistical dashboard for up-to-date monitoring of the HIV epidemic. 

CDC reported that between 2008 and 2014, HIV incidence declined by 18 percent in the United States. However, several key disparities are apparent. In 2014, Southern states comprised about one-half of new HIV infections, and gay and bisexual men accounted for approximately 70 percent of new HIV infections. Additionally, incidence did not decline for Black gay and bisexual men over this time frame. Further, incidence increased among Latino gay and bisexual men and also increased among gay and bisexual men ages 25 to 34. 

While the overall 18 percent decline from 2008 to 2014 is welcome news, we must not celebrate too quickly. In order to understand the magnitude and meaning of an 18 percent decline in any public health metric, we must compare it to previously set national goals. The National HIV/AIDS Strategy (NHAS) set forth by President Obama’s administration in 2010 called for a 25 percent reduction in HIV incidence by 2015. Did we make it?

CDC estimates that HIV incidence in 2010 was 41,600; in 2014 it was 37,600. This decline of approximately 4,000 new HIV infections through 2014 reflects a roughly 9.6 percent drop; less than halfway to the national goal of 25 percent reduction by 2015 (though future updates from CDC for HIV incidence in 2015 will be important to monitor in this regard).

This 9.6 percent drop from 2010 through 2014 is similar to a 9.1 percent estimate we published last year using a somewhat different methodology; in our previous paper, we modeled incidence for 2015 as well and estimated that from 2010 through 2015, HIV incidence in the United States is likely to have dropped roughly 11.1 percent. 

Both our previous modeling efforts and CDC’s new HIV incidence estimates suggest that from 2010 through 2015, HIV incidence declined in the United States, but made it not even halfway to the 25 percent reduction goal. This important point alerts us to the fact that HIV prevention, care and supportive housing efforts in the United States are still not at the scale necessary to meet the original NHAS goals.

At a time when some decision makers are considering possibly repealing and/or replacing the Affordable Care Act, which we know provided critical health insurance access for persons living with HIV and helped to avoid HIV transmission, we should instead be focusing as a nation on expanding critical HIV-related services and access to comprehensive care. The NHAS provides a clear roadmap in this regard. 

Further, the health disparities, especially for gay and bisexual men of color and gay and bisexual men in young adulthood, are clearly unacceptable and must be addressed with culturally relevant, evidence-based, comprehensive wellness services that address HIV and health in a holistic manner.

The same is true for the disparities seen in the Southern United States; this unequal geographic impact of the epidemic, which is mirrored by the burden of other diseases such as diabetes and heart disease, has been known for far too long for such disparities to continue to exist.

These inequities challenge us to once again recommit ourselves to addressing critical social determinants of public health, such as stable housing, food security, affordable health care, and non-stigmatizing health care delivery systems (among other key social determinants). 

We believe that it is important to continue to keep our eyes squarely on well-articulated national HIV-related goals, and to make the requisite financial and resource investments to scale up evidence-based prevention and care services to reach the goals.

With 2015 in the rearview mirror, we argued last summer in this forum that by 2020, HIV incidence could decline to 23,000 if 90 percent of persons living with HIV were diagnosed, 90 percent of diagnosed persons were linked to and retained in quality care services, and 90 percent of persons in care achieved viral suppression, goals consistent with the updated NHAS. While the nation is inching closer to 90 percent awareness that one is living with HIV, we have much work to do to achieve the retention in quality care and viral suppression goals. 

That more work remains should not hinder our cause, but instead motivate us to strive for such milestones. As President Obama said when he released the first NHAS in July 2010 at the White House, “The question is not whether we know what to do, but whether we will do it.” For our communities most heavily and disproportionately impacted by HIV and for all our loved ones whose lives have been lost to HIV, we say that we must do it.

David Holtgrave, PhD, is a professor at the Johns Hopkins Bloomberg School of Public Health in Baltimore and chair of the department of health, behavior and society. Robert Bonacci, MD, MPH, is a resident physician of the department of medicine at Brigham and Women’s Hospital in Boston. The views stated in this post are those of the authors and do not necessarily express the position or views of their employers. This article was originally published on The Huffington Post.

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