HIV Care Outcomes Among Hispanics or Latinos with Diagnosed HIV Infection — United States, 2015

Data from CDC's National HIV Surveillance System (NHSS)* are used to monitor progress toward achieving national goals set forth in the Division of HIV/AIDS Prevention's Strategic Plan (1) and other federal directives† for human immunodeficiency virus (HIV) testing, care, and treatment outcomes and HIV-related disparities in the United States. Recent data indicate that Hispanics or Latinos§ are disproportionately affected by HIV infection. Hispanics or Latinos living with diagnosed HIV infection have lower levels of care and viral suppression than do non-Hispanic whites but higher levels than those reported among blacks or African Americans (2). The annual rate of diagnosis of HIV infection among Hispanics or Latinos is three times that of non-Hispanic whites (3), and a recent study found increases in incidence of HIV infection among Hispanic or Latino men who have sex with men (4). Among persons with HIV infection diagnosed through 2013 who were alive at year-end 2014, 70.2% of Hispanics or Latinos received any HIV medical care compared with 76.1% of non-Hispanic whites (2). CDC used NHSS data to describe HIV care outcomes among Hispanics or Latinos. Among male Hispanics or Latinos with HIV infection diagnosed in 2015, fewer males with infection attributed to heterosexual contact (34.6%) had their infection diagnosed at an early stage (stage 1 = 12.0%, stage 2 = 22.6%) than males with infection attributed to male-to-male sexual contact (60.9%: stage 1 = 25.2%, stage 2 = 35.7%). The percentage of Hispanics or Latinos linked to care after diagnosis of HIV infection increased with increasing age; females aged 45-54 years with infection attributed to injection drug use (IDU) accounted for the lowest percentage (61.4%) of persons linked to care. Among Hispanics or Latinos living with HIV infection, care and viral suppression were lower among selected age groups of Hispanic or Latino males with HIV infection attributed to IDU than among males with infection attributed to male-to-male sexual contact and male-to-male sexual contact and IDU. Intensified efforts to develop and implement effective interventions and public health strategies that increase engagement in care and viral suppression among Hispanics or Latinos (3,5), particularly those who inject drugs, are needed to achieve national HIV prevention goals.

Data from CDC's National HIV Surveillance System (NHSS)* are used to monitor progress toward achieving national goals set forth in the Division of HIV/AIDS Prevention's Strategic Plan (1) and other federal directives † for human immunodeficiency virus (HIV) testing, care, and treatment outcomes and HIV-related disparities in the United States.Recent data indicate that Hispanics or Latinos § are disproportionately affected by HIV infection.Hispanics or Latinos living with diagnosed HIV infection have lower levels of care and viral suppression than do non-Hispanic whites but higher levels than those reported among blacks or African Americans (2).The annual rate of diagnosis of HIV infection among Hispanics or Latinos is three times that of non-Hispanic whites (3), and a recent study found increases in incidence of HIV infection among Hispanic or Latino men who have sex with men (4).Among persons with HIV infection diagnosed through 2013 who were alive at year-end 2014, 70.2% of Hispanics or Latinos received any HIV medical care compared with 76.1% of non-Hispanic whites (2).CDC used NHSS data to describe HIV care outcomes among Hispanics or Latinos.Among male Hispanics or Latinos with HIV infection diagnosed in 2015, fewer males with infection attributed to heterosexual contact (34.6%) had their infection diagnosed at an early stage (stage 1 = 12.0%, stage 2 = 22.6%) than males with infection attributed to male-to-male sexual contact (60.9%: stage 1 = 25.2%,stage 2 = 35.7%).The percentage of Hispanics or Latinos linked to care after diagnosis of HIV infection increased with increasing age; females aged 45-54 years with infection attributed to injection drug use (IDU) accounted for the lowest percentage (61.4%) of persons linked to care.Among Hispanics or Latinos living with HIV infection, care and viral suppression were lower among selected age groups of Hispanic or Latino males with HIV infection attributed to IDU than among males with infection attributed to male-to-male sexual contact and male-to-male sexual contact and IDU.Intensified efforts to develop and implement effective interventions and public health strategies that increase engagement in care and viral suppression among Hispanics or Latinos (3,5) 1).Among these persons, 24.5% had infection classified as stage 1 at diagnosis, 33.6% as stage 2, and 23.1% as stage 3 (acquired immunodeficiency syndrome [AIDS]); for 18.8% the stage was unknown (6).Among both males and females, the highest percentage of infections were diagnosed at an earlier stage (stage 1 [24.5%] or stage 2 [33.6%]).By age group, the highest percentage of Hispanics or Latinos whose infection was diagnosed at stage 1 or stage 2 was reported in persons aged 13-24 years (stage 1, 30.8%; stage 2, 41.1%), followed by persons aged 25-34 years (stage 1, 24.3%; stage 2, 36.8%).In general, the percentages of early diagnosis decreased as age increased; among persons aged ≥55 years, 40.1% of infections were diagnosed at stage 3 (Table 1).By transmission category, the highest percentages of Hispanics or Latinos with infection diagnosed at an earlier stage of HIV disease were among females with infection attributed to heterosexual contact (stage 1, 27.2%; stage 2, 29.2%).Males with infection attributed to heterosexual contact accounted for the lowest percentages of early diagnoses (stage 1, 12.0%; stage 2, 22.6%).
Overall, 5,059 (75.4%) of the 6,707 Hispanics or Latinos with HIV infection diagnosed during 2015 were linked to care within 1 month of diagnosis; the percentage of persons linked to care increased with increasing age (Table 2).By transmission category and age group, males aged ≥55 years with infection attributed to heterosexual contact accounted for the highest  § Data statistically adjusted using multiple imputation techniques to account for missing transmission categories.¶ Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.** Includes persons with diagnosed infection attributed to hemophilia, blood transfusion, perinatal exposure, and risk factors not reported or not identified.
percentage of persons linked to care (88.0%), whereas females aged 45-54 years with infection attributed to IDU accounted for the lowest percentage (61.4%).
Among 141,929 Hispanics or Latinos aged ≥13 years living with diagnosed HIV infection in 38 jurisdictions in 2015, 70.2% received care, and 58.3% were retained in care (Table 3), with males having lower receipt of care (69.0%) and retention in care (57.1%) than females (74.6% and 63.0%, respectively).By transmission category and age group, males aged 25-34 years with infection attributed to IDU accounted for the lowest percentages of persons who received (55.7%) and were retained (44.8%) in care.At the most recent test, 58.2% of Hispanics or Latinos had suppressed viral load (Table 3); a higher percentage of females had suppressed viral load (59.7%) than did males (57.8%).Among all age groups, the lowest level of viral load suppression was among persons aged 13-24 years (54.6%);viral load suppression increased with increasing age.Males aged 25-34 years and 35-44 years with infection attributed to IDU had the lowest levels of viral suppression (38.9% and 43.1%, respectively).

Discussion
In 2015, among Hispanics or Latinos aged ≥13 years with diagnosed HIV infection in 38 jurisdictions with complete laboratory reporting, 58.1% of infections were diagnosed at an earlier stage (stage 1 or 2) and another 18.8% at an unknown stage; overall, 75.4% were linked to care within 1 month of diagnosis.Among all Hispanics or Latinos aged ≥13 years living with diagnosed HIV infection at year-end 2014 in these jurisdictions, 58.3% were retained in care, and 58.2% had suppressed viral load.By comparison, the national goals are 85% linkage to care, 90% retention in care, and 80% viral load suppression (1), and the percentages among non-Hispanic whites were 79.9%, 58.5%, and 65.0%, respectively (3).Improving health outcomes for Hispanics or Latinos living with HIV infection is necessary to reduce HIV transmission in the United States.Prompt linkage to care after diagnosis allows early initiation of HIV treatment, which is associated with reduced morbidity, mortality, and transmission of HIV infection (7).What are the implications for public health practice?
Increasing the proportion of Hispanics or Latinos living with HIV infection who are receiving care and treatment will help to achieve the national goals to reduce new infections, improve health outcomes, and decrease health disparities.Among Hispanics or Latinos, targeted strategies for different groups, such as persons who inject drugs, might be needed to achieve improvements in linkage, care, and viral suppression.
Consistent with findings from a previous report on the continuum of HIV care among Hispanics or Latinos with diagnosed HIV infection based on data from 19 jurisdictions, linkage to care was similar for both males and females, retention in care followed a similar pattern across age groups, and males had lower levels of viral suppression than did females (8).The lowest levels of care and viral suppression among Hispanics or Latinos with HIV infection in these 38 jurisdictions were among males with infection attributed to IDU, and the highest levels of care and viral suppression were among heterosexual females.Hispanics or Latinos in the four age groups ≥25 years had similar percentages of retention in care and viral suppression.Those aged 13-24 years had the highest retention in care among all age groups (60.5%) and the lowest viral suppression (54.6%); the reasons for this are not known.Hispanics or Latinos with HIV infection might not seek, receive, or adhere to HIV care or treatment regimens for various reasons, including lack of health insurance, language barriers, and migration patterns (9).HIV programs that focus on care and treatment for Hispanics or Latinos might consider strengthening efforts to link to and retain in care persons with HIV infection and to promote adherence to medication to achieve optimal health outcomes.
The findings in this report are subject to at least two limitations.First, analyses were limited to 38 jurisdictions with complete laboratory reporting of all levels of CD4 and viral load test results; these 38 jurisdictions might not be representative of all Hispanics or Latinos living with diagnosed HIV infection in the United States.Second, comparisons of numbers and percentages by sex, transmission category, and age group should be interpreted with caution because groups vary in size and some have small, unstable numbers.Reported numbers smaller than 12 and their accompanying percentages also should be interpreted with caution.
Increasing the proportion of Hispanics or Latinos living with HIV infection who receive optimal HIV care will help achieve the national goal of reducing racial/ethnic disparities in HIV care outcomes.Through partnerships with federal, state, and local health agencies, CDC is pursuing a high-impact prevention approach to maximize the effectiveness of current HIV prevention and care methods (10).CDC supports projects focused on Hispanics or Latinos to optimize outcomes along the HIV care continuum, such as HIV testing (the first essential step for entry into the continuum of care) and projects that support linkage to, retention in, and return to care for all persons with HIV infection.† † Among Hispanics or Latinos, targeting strategies to groups that bear a disproportionate burden of HIV disease (e.g., persons who inject drugs) could lead to reductions in HIV infections and health inequities and help achieve the national goal of 80% of all persons living with HIV infection having a suppressed viral load.
, particularly those who inject drugs, are needed to achieve national HIV prevention goals.All states, the District of Columbia, and U.S. territories report cases of HIV infection and associated demographic and clinical information to NHSS.CDC analyzed data for persons aged ≥13 years reported through December 2016 from 38 jurisdictions ¶ with complete laboratory reporting.**These jurisdictions accounted for 75.2% of Hispanics or Latinos aged ≥13 years living with diagnosed HIV infection at year-end 2014 in the United States.Stage of disease at diagnosis and linkage to care were assessed among Hispanics or Latinos living in any of the 38 jurisdictions at the time of diagnosis of HIV infection in 2015.For persons who received a diagnosis of HIV infection during 2015, linkage to HIV care within 1 month ¶ The 38 jurisdictions were Alabama, Alaska, California, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Dakota, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia,

TABLE 1 . Number of diagnoses of HIV infection among Hispanics or Latinos aged ≥13 years, by stage of disease* -National HIV Surveillance System, 38 jurisdictions, † United States, 2015 Characteristic Total Stage 1 (CD4 ≥500 cells/μL or ≥26%) Stage 2 (CD4 200-499 cells/μL or 14%-25%) Stage 3 (AIDS) (CD4 <200 cells/μL or <14%) Stage unknown (no CD4 information)
The 38 jurisdictions were Alabama, Alaska, California, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Dakota, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.§ Data statistically adjusted using multiple imputation techniques to account for missing transmission categories.¶ Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.** Includes persons with diagnosed infection attributed to hemophilia, blood transfusion, perinatal exposure, and risk factors not reported or not identified. †

TABLE 2 . Number of persons linked to HIV medical care within 1 month after diagnosis of HIV infection among Hispanics or Latinos aged ≥13 years, by age group and selected characteristics -National HIV Surveillance System, 38 jurisdictions,* United States, 2015
Abbreviation: HIV = human immunodeficiency virus.* The 38 jurisdictions were Alabama, Alaska, California, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Dakota, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.† One or more CD4 or viral load tests performed within 1 month after HIV diagnosis during 2015.

466 (77.1) 3,506 (60.5) 3,161 (54.6) Age 25-34 yrs † †
2% were virally suppressed.The lowest levels of care and viral suppression were among males with infection attributed to injection drug use, and the highest levels of care and viral suppression were among heterosexual females.Hispanics or Latinos in the four age groups ≥25 years had similar percentages of retention and viral suppression.Those aged 13-24 years had the highest retention in care among all age groups (60.5%), but had the lowest overall viral suppression (54.6%).