An Overview of HIV Among Key Populations in the United States

Greg Millett, Vice President of amfAR, The American Foundation for AIDS Research, provided an overview of HIV among key populations in the United States. Noting that there are 50,000 new infections per year in the United States, Millett explained that statistics showing falling rates of infection can mask differences between populations. For example, there has been no overall change in new infection rates among MSM for over a decade, and there has been a slight increase among young MSM.

There are also racial disparities. Citing a 2008 paper by Irene Hall, Millet explained that, in the US, the lifetime risk of an HIV diagnosis in white men is 1/104, compared to 1/35 for Latino men and 1/16 for black men. The risk of an HIV diagnosis in white women is 1/588, compared to 1/114 for Latina women and 1/30 for black women. In terms of men who have sex with men (MSM), the lifetime risk of an HIV diagnosis is 1/6 for white MSM, compared to 1/5 for Latino MSM and 1/3 for black MSM. Millet emphasized that, although black gay men only account for 0.2% of the US population, they account for one quarter of all new infections each year, and half of new infections among the black community.

Hall’s paper also demonstrates differing rates of new infections among trans women, with the lifetime risk for HIV diagnosis among white trans women at 1/6, compared to 1/3-1/6 for Latina trans women and 1/2 for black trans women.

Millet explained that, although the United States has a low overall prevalence of HIV, rates of new infections among specific populations are as high as or higher than those found in low-income countries.

We’re not only failing people who are living with HIV generally in the United States, we’re failing these specific populations in particular, across each part of the continuum.

Although the CDC reports a decline in HIV diagnoses among people who use injection drugs, Millet explained that recent years have seen an opioid epidemic in rural areas, culminating in a 2015 HIV outbreak among people who use injection drugs in rural Indiana. In a town of 24,000 people, over 160 were newly diagnosed with HIV; by way of comparison, New York City has a population of 8,000,000 and only 50 new HIV diagnoses were attributed to injection drug use in 2014. For Millett, this signals the need to find out what’s taking place in rural counties to cause this disparity.
Across the HIV prevention, engagement and care cascade, Millett identified a pattern in which non-whites, youth, people who use injection drugs and men (other than men who have sex with men) are less likely to know they are HIV-positive, less likely to engage with and remain in care, and less likely to achieve viral suppression. He explained that recent studies had shown that, compared to adults of any race and non-black youth, black youth had the lowest probability of achieving viral suppression.

Gender Disparities and Immigration

Turning his attention to disparities faced by women in the US, Millett noted that, on average, women are diagnosed with higher CD4 counts than men and spend less time in care and on antiretroviral treatment. Women are also less likely to use primary care services as opposed to emergency services, and some studies show that women have higher mortality rates. Meta analyses have found that up to 30% of women living with HIV in the US also have post-traumatic stress disorder, and 55% report experiencing intimate partner violence. Statistics also show that people with recent trauma are four times more likely to fail antiretroviral treatment and that intimate partner violence doubles the risk of death.

A recent study by Michael Mugavero and colleagues found that people living with HIV who have experienced a greater number of stressful events, including traumatic events, were less likely to adhere to treatment. Reflecting on this study, Millet emphasized that we need to consider the ramifications for women and homeless youth.

In terms of immigration, studies have shown a higher prevalence of opportunistic infections and hospitalizations among foreign-born Latinos (as compared to native-born Latinos). Along the US-Mexico border, 46% of Latinos are diagnosed late, as compared to 37% of whites – Spanish-speaking and Puerto Rican Latinos are even more likely to be diagnosed late.

Regional and Structural Disparities

Millett explained that AIDS diagnoses are higher in the southern United States, that the fatality rate is greatest in the south, and that structural disparities, including insurance, low income, housing and food security predict whether and where people will fall off the cascade.

Millett’s concern over regional disparities was echoed by Chris Beyrer, in a separate presentation the following day. Beyrer reiterated that, while new infection rates are falling among people who use injection drugs in the US as well as among people who contract HIV through heterosexual contact, new infection rates among men who have sex with men are rising, especially in the south. “If there’s a new face of the HIV epidemic in the United States,” he said, “it’s a southern one.”

Millet emphasized that racial disparities persist at every stage of the cascade, and explained that black men who have sex with men are less likely to have high incomes or health insurance, compared to white men who have sex with men. In general, African Americans are more likely to die from HIV after diagnosis, partly due to low income.

Even with the Affordable Care Act, there are disparities that are going to persist.

Millett explained that studies of health care within the US military – a setting where, theoretically, everyone has equal access to care – still revealed geographic variation and racial disparities in health outcomes.

Promising Strategies

Millett concluded by highlighting promising strategies to overcome health disparities and improve outcomes across the cascade such as programs in Washington DC that proved needle exchanges can save lives and that expanding HIV testing reduces AIDS diagnoses. He also praised localities such as New York State and San Francisco that, in response to the national HIV strategy, have come up with plans to end HIV.

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