The lifetime risk that a person will be diagnosed with HIV is dropping in the U.S., but glaring and longstanding disparities persist by race and sex, according to new research presented by the Centers for Disease Control and Prevention (CDC) at CROI 2022, this year’s virtual Conference on Retroviruses and Opportunistic Infections.
Sonia Singh, Ph.D., an epidemiologist with the CDC, presented the study’s findings, in which researchers used 2017 to 2019 data from the National HIV Surveillance System (NHSS) alongside mortality and census population data to estimate the chances for HIV diagnosis over a lifetime. Researchers also compared their findings to a prior analysis based on 2010 to 2014 data presented at CROI 2016 to determine whether HIV risk was increasing or decreasing.
The researchers found that HIV risk is decreasing for Americans overall. They estimated that the lifetime risk of an HIV diagnosis for all people in the U.S. was 1 in 120 during the 2017 to 2019 period, an 11% decrease compared to the last time these numbers were crunched using 2010 to 2014 data, which put the odds at 1 in 106. “Big picture, prevention is working,” Singh said.
But the data also show that progress has been slow and uneven, with at-best mixed success in closing large racial gaps. The analysis presented at CROI this week, compared to 2010 to 2014 data, found the possibility of receiving an HIV diagnosis over a lifetime:
Significantly decreased for Native Hawaiian and Pacific Islander females (-59%), Black females (-56%), Asian females (-47%), Black males (-35%), white males (-30%), and Latina females (-26%).
Somewhat decreased for American Indian and Alaska Native females (-9%), Native Hawaiian and Pacific Islander males (-9%), Latino males (-4%), and Asian males (-7%).
Increased for American Indian and Alaska Native males (+10%) and white females (+1%).
The CDC data presented at CROI 2022 only stratified results by male or female; no findings were offered regarding transgender or non-binary individuals. This absence is consistent with the prior report presented at CROI 2016, which garnered significant community criticism at the time.
Unlike the 2016 presentation, Singh’s CROI 2022 presentation also did not stratify the results by a person’s presumed HIV transmission category. No new data were available regarding lifetime diagnosis risk for men who have sex with men, heterosexuals, or people who inject drugs. “A future analysis will incorporate the updated population estimates by transmission category,” Singh said, though she noted that her research team did not have a timeline for the release of that analysis.
The 2016 report notably estimated that the lifetime HIV risk for Black men who have sex with men in the U.S. was one in two, which triggered sharp community reaction.
Breaking Down the Data: U.S. Lifetime HIV Diagnosis Risk By Sex, Race, and State
For U.S. males today, the overall risk of acquiring HIV is still much higher (at 1 in 76) than for females (1 in 309), CDC data show.
The disparities are even more stark when race is considered. Black males in 2017 to 2019 faced a 1 in 27 risk of HIV diagnosis over a lifetime—an improvement over 1 in 20 in the 2010 to 2014 survey, but still well above the risk for other racial groups.
The full racial breakdown is as follows:
Geography also matters when it comes to HIV risk. Singh presented a state-by-state breakdown of the 2017 to 2019 data, which also included Washington, D.C., though it is a city. The District of Columbia also had the highest lifetime HIV diagnosis risk on the map, at 1 in 39, according to the CDC. Of the states, residents of Georgia faced the highest lifetime risk of HIV diagnosis (1 in 59), followed by Florida and Louisiana (both at 1 in 63). By contrast, Wyoming residents faced the lowest risk, at 1 in 655. Residents of the U.S. South, broadly, faced a much higher risk of HIV than any other region.
The overall reduction in lifetime HIV diagnosis risk appears to complement the CDC’s latest HIV surveillance figures, which suggest that significant gains have been made in boosting the use of pre-exposure prophylaxis (PrEP) for HIV prevention in the U.S. As of 2020, approximately 25% of 1.2 million people who were categorized as potentially benefiting from PrEP had received a prescription, compared to about 3% in 2015.
“This analysis assumes 2017 to 2019 HIV diagnosis rates will continue and does not account for potential reductions in HIV transmission that could occur in the future,” Singh noted. The data also predated the global onset of the COVID-19 pandemic, which dramatically reduced HIV testing rates in the U.S. in 2020.
New Lifetime HIV Diagnosis Risk Estimates Leave Many Groups in the Dark
Singh acknowledged limitations of the latest survey, including the lack of data on lifetime risk of HIV for people who inject drugs, as well as gay, bisexual, or other men who have sex with men—all of whom were accounted for in the 2016 report. “We are working on this data,” Singh said. She also stated that, while the CDC did have updated data on Latinx individuals that included a breakdown of people born within versus outside the U.S., such data have not yet been published; “that is something we can consider for an upcoming analysis,” she said.
Meanwhile, Jim Pickett, a leading longtime HIV prevention advocate based in Chicago, expressed frustration with another study limitation: its exclusion of categories for trans women and trans men. He said the omission of complete transgender data was “unacceptable.”
“The entire time I’ve been in the HIV field, trans people have been left out of surveys,” Pickett told TheBodyPro. “Their numbers may be smaller, but their vulnerability is huge.” The CDC’s 2021 HIV Surveillance Report surveyed 1,608 trans women living in seven major U.S. cities and found that 4 in 10 respondents (42.2%) were living with HIV.
Commenting on the data broadly, Singh said that HIV policy experts must “continue to address disparities and deliver key prevention strategies in innovative ways to those who could most benefit” in an effort to end inequities. “These outcomes are estimates and are not inevitable if every person who could benefit has equitable access to highly effective HIV prevention and treatment tools that are available now,” she said.
While acknowledging some positive movement, Pickett told TheBodyPro that he still finds the huge disparities in HIV risk “frustrating.”
“We’ve known about these disparities for decades,” Pickett said, urging the public health community to not only connect people to necessary resources, but to address systemic structural determinants of health such as housing, employment, and education. “When people are housed, they’re more likely to stay HIV negative. When you can’t make a living wage, you’re more vulnerable [to HIV]. I wish someone at the CDC would clearly tell policy advocates what should be done about these numbers,” he said.
The study abstract, “Estimating the Lifetime Risk of a Diagnosis of HIV Infection in the United States,” is available online. Registrants of CROI 2022 can also watch Singh's study presentation as part of the oral abstract session entitled, “Evolving Epidemiology of HIV and SARS-CoV-2.” (CROI 2022 registration is not open to the public.)
Myles Helfand contributed reporting to this article.