Gay, bisexual, and other men who have sex with men (MSM) represent approximately 2% of the United States population, yet are the risk group most affected by human immunodeficiency virus (HIV).1 In 2010, among persons newly infected with HIV, 63% were MSM;2 among persons living with HIV, 52% were MSM.3 The three goals of the National HIV/AIDS Strategy are to reduce new HIV infections, to increase access to care and improve health outcomes for persons living with HIV, and to reduce HIV-related health disparities.4 In July 2013, the HIV Care Continuum Initiative was established by executive order to mobilize and accelerate federal efforts to increase HIV testing, services, and treatment along the continuum.5 To meet the 2015 targets of the National HIV/AIDS Strategy, 85% of MSM diagnosed with HIV should be linked to care, 80% should be retained in care, and the proportion with an undetectable viral load (VL) should be increased by 20%. To assess progress toward meeting these targets, CDC assessed the level at each step of the continuum of care for MSM by age and race/ethnicity. CDC analyzed data from the National HIV Surveillance System (NHSS)* and the Medical Monitoring Project (MMP)† for MSM with diagnosed HIV infection. The results indicated that 77.5% were linked to care, 50.9% were retained in care, 49.5% were prescribed antiretroviral therapy (ART), and 42.0% had achieved viral suppression. Younger MSM and black/African American MSM had lower levels of care compared with older MSM and those of all other races/ethnicities. Interventions aimed at MSM are needed that increase linkage to care, retention in care, and ART use, particularly among MSM aged <25 years and black/African American MSM.
Data from NHSS in 2010, reported to CDC through December 2012, were used to determine the numbers of MSM aged ≥13 years newly diagnosed and living with HIV and the numbers and percentages linked to care and retained in care. Nineteen jurisdictions met the criteria for the collection and reporting of CD4+ T-lymphocyte (CD4) and VL test results,§ the data used to assess linkage and retention in care. Linkage to care¶ was estimated among MSM with new HIV diagnoses during 2010 who resided in any of the 19 jurisdictions at diagnosis. Retention in care** was assessed among MSM with HIV diagnosed by December 31, 2009, who resided in any of the 19 jurisdictions at diagnosis and were alive on December 31, 2010. Data were statistically adjusted for missing HIV transmission categories.6
Data from MMP were used to estimate ART prescription†† and viral suppression§§ among MSM aged ≥18 years using methods described previously.7 The MMP values are weighted national estimates of the numbers of MSM who received medical care during January-April 2010 and had documentation of ART prescription and viral suppression. Percentages were estimated among MSM whose HIV infection was diagnosed by December 31, 2009, and who were alive on December 31, 2010, in the United States and Puerto Rico (denominators were based on NHSS data). Data analyses were limited to 2010, the most recent year for which data were available for persons living with HIV infection.
Of the 10,093 MSM with HIV infection diagnosed during 2010 in the 19 jurisdictions, 7,826 (77.5%) were linked to care within 3 months after HIV diagnosis (Table 1). The percentage linked to care increased with age. Those aged 13-24 years had the lowest percentage of linkage to care (71.0%), and those aged 45-54 years had the highest percentage (84.1%). By race/ethnicity, black/African American MSM had the lowest percentage of linkage to care (71.6%), followed by Hispanic/Latino (80.3%) and white MSM (82.9%).
Among the 174,071 MSM aged ≥13 years living with diagnosed HIV on December 31, 2010, in 19 jurisdictions, 50.9% were retained in care (Table 2). Retention in care also increased with age. Those aged 13-24 years had the lowest percentage of retention in care (45.7%), and those aged ≥55 years had the highest percentage (53.5%). By race/ethnicity, black/African American MSM had the lowest percentage of retention in care (46.3%), followed by white (52.1%) and Hispanic/Latino MSM (54.1%).
Of 416,730 MSM aged ≥18 years living with diagnosed HIV infection on December 31, 2010, in the United States and Puerto Rico, 206,461 (49.5%) were prescribed ART (Table 3). The prevalence of ART prescription increased with age. Among those aged 18-24 years, 30.5% were prescribed ART, and among those aged ≥55 years, 67.7% were prescribed ART. By race/ethnicity, black/African American MSM had the lowest level of ART prescription (47.1%), followed by Hispanic/Latino (49.2%) and white MSM (49.6%).
Among the 416,730 MSM living with diagnosed HIV in the United States and Puerto Rico, 42.0% achieved viral suppression at their most recent test (Table 3). Levels of viral suppression increased with age. Those aged 18-24 years had the lowest level of viral suppression (25.9%), and those aged ≥55 years had the highest level (60.8%). By race/ethnicity, black/African American MSM had the lowest level of viral suppression (37.0%), followed by Hispanic/Latino (41.5%) and white MSM (43.9%).
A high percentage of MSM diagnosed with HIV in 2010 were linked to care (77.5%); however, only 50.9% of MSM living with diagnosed HIV infection were retained in care, 49.5% were prescribed ART, and 42.0% had achieved viral suppression. Increasing access to care and sustained treatment is critical for improving health outcomes and to reduce the potential of transmitting HIV among MSM, who are the majority of persons with HIV infection.
At each step of the continuum of care, younger MSM had lower levels of care compared with older MSM. Black/African American MSM had the lowest levels of care compared with those of all other race/ethnicities. Lack of health insurance, stigma, and discrimination might influence whether MSM access medical care, which has implications for each subsequent step along the continuum of care. Implementing effective interventions for young MSM aged <25 years and black/African American MSM could improve outcomes along the continuum of care.
Early awareness of HIV-positive status permits earlier entry into the continuum of care. In 2011, the National HIV Behavioral Surveillance System in 20 cities found that only 49% of MSM aged 18-24 years who tested positive were aware of their HIV infection.8 By race/ethnicity, 54% of black/African American, 63% of Hispanic/Latino, and 86% of white MSM aged ≥18 years who tested positive were aware of their infection. Persons who are aware of their HIV-positive status are less likely to engage in risky behaviors that increase the probability of transmitting HIV to sex partners9 and can enter into care and treatment earlier, further improving health outcomes. CDC recommends routine HIV screening for all persons aged 13-64 years in health care settings. Health care providers should subsequently test all persons likely to be at high risk for HIV at least annually, including MSM.9 Among MSM who reported negative or unknown HIV status in 2011 in the National HIV Behavioral Surveillance System, 67% reported testing for HIV during the past year.10 Sexually active, HIV-negative MSM might benefit from more frequent testing, such as every 3-6 months.10
The findings in this report are subject to at least four limitations. First, analyses based on the NHSS data are from 19 jurisdictions with complete CD4 and VL reporting. Data from these 19 areas might not be representative of data on all MSM diagnosed with HIV infection in the United States. Data from these areas represent 42% of MSM diagnosed with HIV infection. Second, overall national data might not be applicable to all states. Third, analyses in this study are based on different populations. Linkage to care and retention in care were based on data for persons aged ≥13 years from 19 jurisdictions, whereas ART prescription and viral suppression were based on weighted estimates of persons receiving care who were aged ≥18 years and resided in the United States and Puerto Rico. In addition, ART use should be interpreted in the context of U.S. Department of Health and Human Services guidelines¶¶ that were in effect at the time of data collection; ART might have been prescribed less frequently for those with CD4 counts >500 cells/mm3. Finally, documentation of the most recent viral load might not be indicative of consistent viral suppression in this population over time.
CDC has adopted a high-impact prevention approach to reduce the number of new HIV infections by using a combination of scientifically proven, cost-effective, and scalable interventions targeted to relevant populations and geographic areas for increasing the impact of HIV prevention efforts and achieving the goals of the National HIV/AIDS Strategy.*** CDC currently funds prevention, surveillance, research, and evaluation programs for a diverse range of MSM, including young racial/ethnic minority MSM.††† The findings in this report highlight the need for continued expansion of prevention, care, and treatment efforts for achieving improvement in linkage to care, retention in care, and viral suppression for MSM, particularly MSM aged <25 years and black/African American MSM. Given that MSM account for more than half of new infections and comprise approximately half of persons living with HIV infection, to reduce HIV incidence, improve health outcomes, and reduce HIV-related health disparities in the United States, the prevention and care needs of MSM must be addressed.
By Sonia Singh, Ph.D., Heather Bradley, Ph.D., Xiaohong Hu, M.S., Jacek Skarbinski, M.D., H. Irene Hall, Ph.D., and Amy Lansky, Ph.D., are with the Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC (Corresponding author: Sonia Singh, firstname.lastname@example.org, 404-639-6337).