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HIV Infections Attributed to Male-to-Male Sexual Contact -- Metropolitan Statistical Areas, United States and Puerto Rico, 2010

By Hollie Clark, M.P.H., H. Irene Hall, Ph.D., Tian Tang, M.S., Shericka Harris, M.P.H., Anna Satcher Johnson, M.P.H., and Joseph Prejean, Ph.D.

November 30, 2012

Human immunodeficiency virus (HIV) infections attributed to male-to-male sexual contact comprised 64% of the estimated new HIV infections in the United States in 2009.1 Assessing the geographic distribution of HIV infection by transmission category can help public health programs target prevention resources to men who have sex with men (MSM) in areas where HIV infection from male-to-male sexual contact is most frequent. In 2004, CDC published data on acquired immunodeficiency syndrome diagnoses among MSM and others by metropolitan statistical area (MSA).2 To examine geographic differences in the prevalence of HIV infection from male-to-male sexual contact among persons aged ≥13 years in the United States and Puerto Rico, CDC estimated the number of HIV infections in persons newly diagnosed in 2010 and analyzed them by transmission category and location. Results indicated that HIV infections attributed to male-to-male sexual contact made up the largest percentage of HIV infections in MSAs (62.1%), smaller metropolitan areas (56.1%), and nonmetropolitan areas (53.7%). Of the 28,851 infections attributed to male-to-male sexual contact, 23,559 (81.7%) were in MSAs, and 11,410 (48.4%) of those infections were in seven MSAs that represented 31.7% (53,169,004 of 167,919,694) of the overall population aged ≥13 years in the MSAs that were assessed. These data support planning for targeted interventions to prevent HIV acquisition and transmission by male-to-male sexual contact among MSM, particularly in those areas most affected.

HIV infections in persons newly diagnosed in 2010 that were reported to the National HIV Surveillance System through June 2011 were examined from 564 locations, including 103 MSAs, 263 smaller metropolitan areas, and 198 nonmetropolitan areas in the United States and Puerto Rico.* Reported diagnoses of HIV infection for persons aged ≥13 years were tallied, and numbers of diagnoses overall and by transmission category were estimated. Data were adjusted for reporting delays and missing HIV risk factors but not for underreporting.3,4 Because a substantial proportion of persons with diagnosed HIV infection are reported to CDC without an identified risk factor, multiple imputation methods are used to assign transmission categories to those persons whose diagnoses are reported without a risk factor.4 Multiple imputation is a statistical approach in which missing transmission categories for each person are replaced with plausible values that represent the uncertainty regarding the actual, but missing, values.5

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Estimates were calculated for new diagnoses of HIV infection attributed to male-to-male sexual contact, injection-drug use, male-to-male sexual contact and injection-drug use, heterosexual contact, and other HIV risk factors or modes of transmission (e.g., hemophilia, blood transfusion, or perinatal exposure). Transmission categories are assigned, based on the single risk factor (of all identified risk factors) that was most likely responsible for HIV transmission.6,7 An exception is male-to-male sexual contact and injection-drug use, which makes up a separate transmission category. Estimates were not calculated for locations that did not have confidential name-based HIV reporting in place by January 2007 (or had not reported these data to CDC since at least June 2007) to enable the calculation of reporting delays. Excluded were locations in Hawaii, Maryland, Massachusetts, Vermont, and the District of Columbia.6

Of the estimated 37,934 persons aged ≥13 years with a diagnosis of HIV infection who resided in MSAs in the United States and Puerto Rico during 2010, a total of 23,559 (62.1%) had HIV infection attributed to male-to-male sexual contact; 10,128 (26.7%) had HIV infection attributed to heterosexual contact, 3,070 (8.1%) to injection-drug use, 1,145 (3.0%) to male-to-male sexual contact and injection-drug use, and 33 (0.1%) to other modes of transmission (Table 1). Among smaller metropolitan areas, 3,182 (56.1%) of 5,677 HIV infections were attributed to male-to-male sexual contact, and among nonmetropolitan areas, 1,756 (53.7%) of 3,272 HIV infections were attributed to male-to-male sexual contact (Table 1). Of the 28,851 HIV infections among persons with infection attributed to male-to-male sexual contact overall, 23,559 (81.7%) were among persons living in MSAs. Persons aged ≥13 years living in MSAs comprised 65.5% (167,919,694 of 256,388,562) of the total population of persons aged ≥13 years for the areas that were assessed (103 MSAs, 263 smaller metropolitan areas, and 198 nonmetropolitan areas).

A total of 11,410 (48.4%) of the 23,559 estimated HIV infections attributed to male-to-male sexual contact were among persons who resided in seven MSAs: New York, New York, New Jersey, Pennsylvania (3,347); Los Angeles, California (2,589); Miami, Florida (1,481); Atlanta-Sandy Springs-Marietta, Georgia (1,059); Chicago, Illinois, Indiana, Wisconsin (1,011); Dallas, Texas (995), and Houston-Baytown-Sugar Land, Texas (928) (Table 2). Persons aged ≥13 years residing in these seven MSAs comprised 31.7% (53,169,004 of 167,919,694) of the total population of persons aged ≥13 years for the MSAs that were assessed. The four largest percentages of HIV infections attributed to male-to-male sexual contact in MSAs were in Los Angeles, California (81.9%), Fresno, California (80.8%), Modesto, California (78.8%), and Oxnard-Thousand Oaks-Ventura, California (78.2%).§

Reported by: Hollie Clark, M.P.H., H. Irene Hall, Ph.D., Tian Tang, M.S., Shericka Harris, M.P.H., Anna Satcher Johnson, M.P.H., Joseph Prejean, Ph.D., Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding contributor: Hollie Clark, hclark@cdc.gov, 404-639-3983.

Editorial Note

The results of this analysis indicate that the majority of HIV infections in newly diagnosed persons aged ≥13 years in 2010 were attributed to male-to-male sexual contact. The percentages of HIV infections attributable to male-to-male sexual contact were higher in MSAs, compared with smaller metropolitan areas and nonmetropolitan areas. Among the MSAs examined, seven accounted for 48.4% of the persons with HIV infection attributable to male-to-male sexual contact. The four MSAs with the largest percentages of HIV infections attributed to male-to-male sexual contact were located in California. These results highlight the disproportionate burden of HIV infection among MSM, who were estimated to comprise approximately 3.9% of the male population aged ≥13 years in 2008 in the United States.8

The geographic concentration of HIV infection reflects the higher risk for HIV transmission in areas with larger populations, greater prevalence of HIV infection attributed to male-to-male contact (e.g., MSAs compared with smaller areas), and possibly a greater prevalence of MSM living in the community. Effective interventions that could reduce the number of HIV infections in MSAs include HIV testing, HIV care and treatment, and risk-reduction counseling.

The findings in this report are subject to at least three limitations. First, HIV infection surveillance locations in five areas were excluded because they had not had confidential name-based reporting in place by January 2007 or had not reported these data to CDC since at least June 2007. The effect of this limitation is unknown. Second, comparisons were made based on estimated percentages of diagnoses instead of HIV diagnosis rates. To evaluate disparities in HIV risk between groups, HIV diagnosis rates should be calculated by applying population denominators for persons within each transmission category; however, such population estimates currently are unavailable for MSAs, smaller metropolitan areas, and nonmetropolitan areas. Finally, transmission category estimates were adjusted for missing risk factor information. Whether these adjustments introduce any bias in overestimation or underestimation of percentages of HIV infection attributed to specific categories is unknown. Adjusted estimates should be interpreted with caution, particularly when numbers are small (i.e., less than 12).

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CDC's High-Impact HIV Prevention program relies on geographic targeting of resources and proven, cost-effective interventions to achieve the goals of the National HIV/AIDS Strategy, which include reducing the number of persons who become infected with HIV, increasing access to care and optimizing health outcomes for persons living with HIV, and reducing HIV-related health disparities.** The results of this analysis underscore the uneven geographic distribution of the burden of HIV infection in MSAs in the United States and Puerto Rico. The geographic disparity in HIV burden also indicates a need to target MSM who bear a large percentage of the burden of infection in areas where persons are at greatest risk for HIV transmission. Health departments, community-based organizations, and other agencies can use these results in planning interventions in their areas to reduce HIV infection and transmission.


References

  1. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006-2009. PLoS One 2011;6:e17502.
  2. CDC. AIDS cases, by geographic area of residence and metropolitan statistical area of residence, 2004. HIV/AIDS surveillance supplemental report. Vol. 12, No. 2. Atlanta, GA: US Department of Health and Human Services, CDC; 2006. Accessed November 21, 2012.
  3. Song R, Green TA. An improved approach to accounting for reporting delay in case surveillance systems. JP Journal of Biostatistics 2012;7:1-14.
  4. Harrison KM, Kajese T, Hall HI, Song R. Risk factor redistribution of the national HIV/AIDS surveillance data: an alternative approach. Public Health Rep 2008;123:618-27.
  5. Rubin, DB. Multiple imputation for nonresponse in surveys. New York, NY: John Wiley & Sons, Inc.; 1987.
  6. CDC. Diagnoses of HIV infection and AIDS in the United States and dependent areas, 2010. HIV surveillance report, 2010. Vol. 22. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Accessed November 21, 2012.
  7. CDC. Terms, definitions, and calculations used in CDC HIV surveillance publications. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Accessed November 21, 2012.
  8. Purcell DW, Johnson CH, Lansky A, et al. Estimating the population size of men who have sex with men in the United States to obtain HIV and syphilis rates. Open AIDS J 2012;6:98-107.

* MSAs have populations ≥500,000; smaller metropolitan areas have populations of 50,000-499,999, and nonmetropolitan areas are those with populations <50,000. Additional information available at www.whitehouse.gov/sites/default/files/omb/assets/bulletins/b10-02.pdf.

† Includes populations for adults and adolescents living in seven MSAs that were excluded from the total estimated number of HIV infections attributed to male-to-male contact.

§ Only percentages based on estimated numbers ≥12 are presented.

¶ Additional information available at www.cdc.gov/hiv/strategy/hihp/pdf/dhap_policy_maker.pdf.

** Additional information available at www.whitehouse.gov/administration/eop/onap/nhas.


What is already known on this topic?

In 2009, an estimated 64% of new human immunodeficiency virus (HIV) infections were attributed to male-to-male sexual contact.

What is added by this report?

Of the estimated 28,851 infections in 2010 attributed to male-to-male sexual contact, 23,559 (81.7%) were in metropolitan statistical areas (MSAs) with populations of 500,000 or more in the United States and Puerto Rico, and 11,410 (48.4%) of those infections were in seven of the MSAs assessed. The four MSAs with the greatest percentages of HIV infections attributed to male-to-male sexual contact were in California.

What are the implications for public health practice?

Effective interventions that could reduce the number of HIV infections in areas where men who have sex with men are at greater risk for HIV infection and transmission by male-to-male contact include HIV testing, HIV care and treatment, and risk-reduction counseling.


TABLE 1. Estimated Number and Percentage* of Diagnoses of HIV InfectionAmong Persons Aged ≥13 Years, by Transmission Category and Size of Location of Residence -- National HIV Surveillance System, United States and Puerto Rico, 2010

TABLE 1. Estimated Number and Percentage* of Diagnoses of HIV Infection Among Persons Aged ≥13 Years, by Transmission Category and Size of Location of Residence -- National HIV Surveillance System, United States and Puerto Rico, 2010
TABLE 2. Estimated Number and Percentage* of Diagnoses of HIV Infection Attributed to Male-to-Male Sexual Contact Among Persons Aged &Ge;13 Years, by Location of Residence -- National HIV Surveillance System, United States and Puerto Rico, 2010

Location of residence

HIV infection attributed to male-to-male sexual contact

Total diagnoses

Reported no.§

Estimated no.

% of total

Reported no.§

Estimated no.

Akron, Ohio

13

21

60.2

33

35

Albany-Schenectady-Troy, New York

28

46

46.4

75

99

Albuquerque, New Mexico

43

57

75.0

70

76

Allentown-Bethlehem-Easton, Pennsylvania, New Jersey

25

35

49.7

63

70

Atlanta-Sandy Springs-Marietta, Georgia

387

1,059

64.5

1,182

1,641

Augusta-Richmond County, Georgia, South Carolina

24

67

52.4

89

128

Austin-Round Rock, Texas

144

186

71.1

239

262

Bakersfield, California

28

50

36.0

112

138

Baltimore-Towson, Maryland

96

--

--

818

--

Baton Rouge, Louisiana

88

146

43.2

312

337

Birmingham-Hoover, Alabama

91

145

60.9

217

238

Boise City-Nampa, Idaho

9

17

60.8

25

27

Boston-Cambridge-Quincy, Massachusetts, New Hampshire

156

--

--

431

--

Bradenton-Sarasota-Venice, Florida

44

55

59.1

85

92

Bridgeport-Stamford-Norwalk, Connecticut

33

55

38.5

107

142

Buffalo-Niagara Falls, New York

51

77

45.8

127

169

Cape Coral-Fort Myers, Florida

28

33

34.1

89

97

Charleston-North Charleston, South Carolina

67

85

63.5

123

134

Charlotte-Gastonia-Concord, North Carolina, South Carolina

204

292

63.7

408

459

Chattanooga, Tennessee, Georgia

19

36

55.1

55

65

Chicago, Illinois, Indiana, Wisconsin

604

1,011

68.9

1205

1,468

Cincinnati-Middletown, Ohio, Kentucky, Indiana

113

164

66.7

226

246

Cleveland-Elyria-Mentor, Ohio

104

169

73.4

213

230

Colorado Springs, Colorado

21

28

72.2

35

38

Columbia, South Carolina

104

142

62.5

209

228

Columbus, Ohio

159

258

75.8

316

340

Dallas, Texas

767

995

68.4

1,334

1,455

Dayton, Ohio

62

75

76.2

90

98

Denver-Aurora, Colorado

201

241

68.2

322

353

Des Moines, Iowa

21

29

68.1

39

43

Detroit, Michigan

244

367

67.6

508

544

Durham-Chapel Hill, North Carolina

41

60

50.3

109

119

El Paso, Texas

77

101

76.1

121

132

Fresno, California

75

94

80.8

97

117

Grand Rapids-Wyoming, Michigan

21

29

69.5

39

42

Greensboro-High Point, North Carolina

66

87

62.6

128

139

Greenville, South Carolina

38

47

64.7

67

73

Harrisburg-Carlisle, Pennsylvania

22

31

54.3

53

57

Hartford-West Hartford-East Hartford, Connecticut

67

98

47.1

164

207

Honolulu, Hawaii

32

--

--

61

--

Houston-Baytown-Sugar Land, Texas

616

928

59.7

1,425

1,553

Indianapolis, Indiana

131

177

65.4

247

270

Jackson, Mississippi

62

104

56.7

167

184

Jacksonville, Florida

154

175

45.2

355

388

Kansas City, Missouri, Kansas

156

185

75.4

223

245

Knoxville, Tennessee

29

36

71.9

46

50

Lakeland, Florida

43

56

45.9

112

122

Lancaster, Pennsylvania

16

18

34.9

46

50

Las Vegas-Paradise, Nevada

249

284

73.4

351

387

Little Rock-North Little Rock, Arkansas

35

69

70.3

89

98

Los Angeles, California

1,575

2,589

81.9

2,335

3,161

Louisville, Kentucky, Indiana

68

128

68.6

170

186

Madison, Wisconsin

20

29

75.1

36

39

McAllen-Edinburg-Pharr, Texas

48

64

67.9

85

94

Memphis, Tennessee, Mississippi, Arkansas

108

231

52.8

395

438

Miami, Florida

1,184

1,481

53.9

2,514

2,749

Milwaukee-Waukesha-West Allis, Wisconsin

95

133

73.4

165

180

TABLE 2. (Continued) Estimated Number and Percentage* of Diagnoses of HIV Infection Attributed to Male-to-Male Sexual Contact Among Persons Aged ≥13 Years, by Location of Residence -- National HIV Surveillance System, United States and Puerto Rico, 2010

Location of residence

HIV infection attributed to male-to-male sexual contact

Total diagnoses

Reported no.§

Estimated no.

% of total

Reported no.§

Estimated no.

Minneapolis-St. Paul-Bloomington, Minnesota, Wisconsin

169

236

69.5

307

340

Modesto, California

12

16

78.8

17

20

Nashville-Davidson-Murfreesboro, Tennessee

158

234

71.5

298

327

New Haven-Milford, Connecticut

34

51

37.7

104

136

New Orleans-Metairie-Kenner, Louisiana

152

244

55.8

404

437

New York, New York, New Jersey, Pennsylvania

2,013

3,347

54.5

4,669

6,140

Ogden-Clearfield, Utah

10

11

83.0

12

13

Oklahoma City, Oklahoma

67

98

62.4

143

157

Omaha-Council Bluffs, Nebraska, Iowa

37

54

60.2

81

90

Orlando, Florida

310

407

59.8

622

682

Oxnard-Thousand Oaks-Ventura, California

25

34

78.2

35

43

Palm Bay-Melbourne-Titusville, Florida

35

44

53.6

75

82

Philadelphia, Pennsylvania, New Jersey, Delaware, Maryland

484

--

--

1,192

--

Phoenix-Mesa-Scottsdale, Arizona

300

361

73.9

453

489

Pittsburgh, Pennsylvania

92

112

67.3

153

166

Portland-South Portland, Maine

16

22

61.9

30

36

Portland-Vancouver-Beaverton, Oregon, Washington

131

158

72.5

198

218

Poughkeepsie-Newburgh-Middletown, New York

20

32

34.4

70

94

Providence-New Bedford-Fall River, Rhode Island, Massachusetts

67

89

60.5

151

147

Provo-Orem, Utah

4

4

66.8

6

7

Raleigh-Cary, North Carolina

114

143

69.3

190

206

Richmond, Virginia

105

147

56.3

217

260

Riverside-San Bernardino-Ontario, California

242

319

71.5

366

447

Rochester, New York

71

105

67.3

118

156

Sacramento-Arden-Arcade-Roseville, California

106

140

59.6

191

234

St. Louis, Missouri, Illinois

202

294

68.3

380

430

Salt Lake City, Utah

32

36

59.0

57

62

San Antonio, Texas

159

207

69.5

273

298

San Diego-Carlsbad-San Marcos, California

372

469

74.5

515

630

San Francisco, California

553

729

70.4

873

1,035

San Jose-Sunnyvale-Santa Clara, California

89

128

70.8

144

180

San Juan-Caguas-Guaynabo, Puerto Rico

138

267

34.3

475

778

Scranton-Wilkes-Barre, Pennsylvania

11

12

34.9

30

34

Seattle, Washington

267

328

74.9

401

438

Springfield, Massachusetts

21

--

--

72

--

Stockton, California

39

51

47.3

87

107

Syracuse, New York

26

38

58.0

49

65

Tampa-St. Petersburg-Clearwater, Florida

317

404

63.6

578

635

Toledo, Ohio

17

24

63.6

35

38

Tucson, Arizona

57

77

73.1

96

105

Tulsa, Oklahoma

46

59

69.8

79

84

Virginia Beach-Norfolk-Newport News, Virginia, North Carolina

131

241

60.4

335

400

Washington, District of Columbia, Virginia, Maryland, West Virginia

589

--

--

1,715

--

Wichita, Kansas

30

35

63.5

49

55

Worcester, Massachusetts

13

--

--

61

--

Youngstown-Warren-Boardman, Ohio, Pennsylvania

9

23

58.7

37

40

Total

16,898

23,559

62.1

35,200

37,934

Abbreviations: HIV = human immunodeficiency virus; MSAs = metropolitan statistical areas.

* Estimates result from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. Cases without reported risk factors were assigned transmission categories using multiple imputation methods.

† Includes all new diagnoses of HIV infection, regardless of stage of disease at diagnosis.

§ Includes reported numbers from 103 MSAs, 263 smaller metropolitan areas, and 198 nonmetropolitan areas.

¶ Includes estimated numbers only from 96 MSAs, 258 smaller metropolitan areas, and 198 nonmetropolitan areas located in states that had implemented confidential name-based HIV infection reporting by at least January 2007 and had reported these data to CDC since at least June 2007. Reported and estimated numbers smaller than 12 or percentages based on estimated numbers smaller than 12 are considered unreliable and should be interpreted with caution.




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