Outcomes Disparities Persist for Black Individuals Living With HIV

Earlier intervention and treatment of HIV among Black Americans living in rural areas is greatly needed, reports the CDC’s most recent Morbidity and Mortality Weekly Report. During 2018, the year on which this report is based, rural location was correlated with the highest rate of late-stage HIV diagnosis (25.2%) vs living in an urban (21.9%) or metropolitan (19.0%) locale.

Late-stage diagnosis, or stage 3 disease, was equated to already living with AIDS at diagnosis.

In contrast, viral suppression at 6 months and linkage to care within 1 month of diagnosis were most likely if patients were living in a metropolitan area (63.8% and 77.2%, respectively) rather than urban (59.7% and 77.0%) and rural (59.6% and 76.7%) areas. Viral suppression is indicated by having less than 200 copies/mL.

Data from the National HIV Surveillance System on 41 states and Washington, DC, were used for this report, with a laboratory reporting cutoff date of December 31, 2019, on 14,502 Black individuals with HIV diagnosed in 2018.

“Access to HIV-related care and treatment services varies by residence area,” the authors noted. “Identifying urban-rural differences in HIV care outcomes is crucial for addressing HIV-related disparities among Black persons with HIV infection.”

Overall, in 2018, the 62.9% of Black Americans 13 years or older who achieved viral suppression and 77.1% linked to care in the month after their diagnosis were far below the 95% goal of the government’s Ending the HIV Epidemic plan. Most lived in metropolitan areas (80.6%), followed by urban (13.2%) and rural (6.2%) areas.

Analyses also revealed these findings:

• Late-stage diagnosis was more common in females than males:
  • Rural: 31.4% vs 23.0%
  • Urban: 23.1% vs 21.5%
  • Metropolitan: 20.6% vs 18.6%
• Individuals aged 45 to 54 years had the highest rates of late-stage diagnoses in rural (47.9%) and metropolitan (31.4%) areas, whereas in urban areas the rate of late-stage diagnoses was highest in those 55 years and older (43.1%).
• Males with heterosexual contact had the highest rates of viral transmission in the evaluated areas (rural, 37.2%; urban, 32.5%; metropolitan, 28.3%).
• Males were less likely than females to link to care and be virally suppressed at 6 months:
  • Rural: 75.2% vs 81.8% and 58.0% vs 64.0%
  • Urban: 75.0% vs 82.7% and 57.8% and 65.1%
  • Metropolitan: 76.4% vs 79.5% and 62.4% vs 68.1%
• Heterosexual virus transmission correlated to the lowest rates of linkage to care among males aged 45 to 54 years in rural (69.9%) and urban (7.1%) areas and those aged 13 to 24 years in metropolitan areas (62.3%).
• Lowest rates of viral suppression at 6 months were seen in persons aged 45 to 54 years in rural (52.1%) and urban (56.4%) areas and those aged 13 to 34 years in metropolitan areas (62.6%).
• Male-to-male sexual contact (44.2%) and heterosexual contact (42.5%) were associated with the greatest likelihood of not being virally suppressed at 6 months in rural and urban areas for men aged 45 to 54 years.
• Males aged 13 to 24 years and 25 to 34 years reporting virus transmission from heterosexual contact (51.7%) and injection drug use (45.0%), respectively, had the lowest rates of 6-month viral suppression in metropolitan areas.

These results highlight the lack of current routine HIV testing and the need for its wider implementation to identify those who have undiagnosed infections, to reduce disparities, and to achieve national prevention goals.

“They likely underscore known differences in health-related behaviors, physical and sociocultural environments, and access to and use of health care systems among Black urban and rural HIV populations,” the authors highlighted. “Broader implementation of routine HIV testing is needed to identify persons with undiagnosed infections and to initiate early treatment, particularly among older persons.”

Patient retention and re-engagement initiatives are especially important to help curb transmission, with top priorities being strategies that target injection drug users, sexually active older adults, geographic disparities, and social determinants of health. Approaches should be culturally appropriate and free from stigma, “to ensure HIV-related health equity,” the authors conclude.

Reference

Lyons SJ, Dailey AF, Yu C, Johnson AS. Care outcomes among Black or African American persons with diagnosed HIV in rural, urban, and metropolitan statistical areas—42 US jurisdictions, 2018. MMWR Morb Mortal Wkly Rep. 2021;70:229-235. doi:10.15585/mmwr.mm7007a1