Source: Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Tammie L. Nelson (TNelson@MarionHealth.org)

The Marion County Public Health Department’s Ryan White Services Program (RWSP) oversees Ryan White Part A, C, and Minority AIDS Initiative grants in the Indianapolis-Carmel Metropolitan Statistical Area (MSA). These programs serve the needs of persons newly infected or living with HIV and out of care and/or uninsured or medically underserved.

Estimating HIV Prevalence: Estimation of the number of people living with HIV (PLWH) but undiagnosed and unaware of their serostatus is frequently revised. The Centers for Disease Control and Prevention (CDC) recently decreased the estimate from 15.8% to 14% of PLWH ≥13 years of age.¹ Based on this estimate, total prevalence in the MSA on December 31, 2013 is thought to have been 6,223 (5,351 diagnosed and 872 undiagnosed).^2,3

Target: The National HIV/AIDS Strategy (NHAS) goal is to increase the percentage of PLWH who are diagnosed and aware of their serostatus to 90%.⁴

Importance of Early Diagnosis: Diagnosis is the first step in the HIV continuum of care. Early diagnosis and linkage to and retention in care have been associated with delayed progression to AIDS and increases in quality and length of life.^5,6,7 These factors also reduce secondary HIV transmission.^5,8,9 Evidence shows that HIV transmission rate is highest among those undiagnosed, accounting for approximately 30% of new HIV infections.¹⁰ Although early diagnosis is most effective when combined with linkage to and retention in care, diagnosis alone can decrease secondary transmission by decreasing risk factors of transmission (i.e., sex with HIV-discordant partners).^10,11,12,13

Who is Most at Risk: CDC estimates attribute the largest differences in percentage of undiagnosed PLWH to age, where estimates decrease from 51.3% in 13-24 year olds to only 5.1% in those 65 and older.¹ Among youth and young adults, those most at risk are minority males.¹⁴ Table 1 provides estimates of the number and percentage, by age, of undiagnosed PLWH in the MSA calculated using national estimates. Note: Generalizing national estimates to the MSA can produce inaccuracies; thus, Table 1 is meant only to provide approximations of undiagnosed PLWH in the MSA.

Table: Diagnosed and Estimated Undiagnosed HIV in the Indianapolis-Carmel Metropolitan Statistical Area: 31Dec2013^1,2

Age (Yrs.)	Diagnosed	Est. % Undiagnosed	Est. No. Undiagnosed
13-19	30	51.3	32
20-24	221	51.3	233
25-34	864	26.0	304
35-44	1253	14.3	209
45-54	1827	8.4	168
55-64	870	6.7	62
65+	215	5.1	12

Overall, a larger percentage of males (14.8%) are thought to be undiagnosed than females (11.5%).¹ A smaller percentage of non-Hispanic White PLWH (11.9%) are thought to be undiagnosed than minorities where 15% of non-Hispanic Black and 15% of Hispanic PLWH are estimated to be undiagnosed.¹

Guidelines for Increasing Diagnosis and Sero-Awareness among PLWH:

Identify and reach out to those most at risk for HIV infection – Identify populations and geographic areas with the greatest HIV burden and design programs to reach them. Populations bearing the greatest burden of HIV in the MSA include MSM, young African American men, and African American women.² Other conditions leading to increased risk of HIV infection in the MSA include IDU, mental illness, former incarceration, and/or homelessness.^{2,14,15,16,17}

Increase readiness of individuals to be tested for HIV – Develop programs to increase awareness of HIV infection and risk reduction methods and strive to decrease stigma related to HIV, sexual identity, substance use, mental health issues, lack of trust in the medical system, and low health literacy.¹⁸ Consider using peer-based outreach programs.¹⁴Design education and risk reduction programs to emphasize the importance of regular HIV screening and early HIV diagnosis.¹⁹ High risk individuals should be tested for HIV at least once annually.¹⁷

Increase access to HIV testing – Consider placing HIV testing sites along bus routes or at non-traditional sites such as community-based organizations, mental health centers, and social service agencies.¹⁸ Eliminate long wait times at testing sites. Provide bilingual staff or language services.¹⁸ Make use of rapid test methods. Consider supporting anonymous testing and home collection kits.¹⁹ Increase testing in health care and correctional facilities.¹⁹

Follow through on those tested – Refer those who test negative to HIV health education and risk reduction programs.¹⁹ Provide post-test counseling for those who test positive. Conduct contact investigations and provide direct partner service notification and testing of sex and needle-sharing partners.¹⁹

Increase routine HIV screening in health care settings – Follow CDC and U.S. Preventive Services Task Force (USPSTF) recommendations of routine HIV screening in: all patients 13-65 years of age (CDC recommends 13-64 year olds be screened and USPSTF recommends 15-65 be screened); younger and older patients who are at increased risk; all pregnant women, including those presenting in labor; and, those seeking treatment for sexually-transmitted disease or tuberculosis.^20,21

Given the strong collaborations and dedication to diagnosing all PLWH in the MSA, the number remaining undiagnosed and unaware of their serostatus should continue to decrease. As you contemplate future programming for your organization, consider employing some of the tactics intended to increase diagnosis. For more information on HIV screening and testing recommendations, visit www.cdc.gov/hiv/guidelines/testing.html.

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1 Centers for Disease Control and Prevention. (2014). Monitoring selected national HIV prevention and care objectives by using HIV surveillance data – United States and 6 dependent areas – 2012. HIV Surveillance Supplemental Report, 19(3).

2 Centers for Disease Control and Prevention. (2015). Enhanced HIV/AIDS Reporting System (eHARS).

3 Previously reported as 6,427 (5,411 diagnosed and 1,016 undiagnosed) based on early prevalence reports and 2013 CDC estimation methods. [Nelson, T. L. (2014, December 5). HIV care updates for the Indianapolis-Carmel Metropolitan Statistical Area. MATEC Indiana Newsletter, 65.].

4 The White House Office of National AIDS Policy. (2010). National HIV/AIDS strategy for the United States.

5 Centers for Disease Control and Prevention. (2013). Prevention benefits of HIV treatment.

6 Centers for Disease Control and Prevention. (2012) Linkage to and retention in HIV Medical Care.

7 Chadborn, T. R., Delpech, V. C., Sabin, C. A., Sinka, K., & Evans, B. G. (2006). The late diagnosis and consequent short-term mortality of HIV-infected heterosexuals (England and Wales, 2000–2004). AIDS, 20(18), 2371–2379.

8 Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour, M. C., Kumarasamy, N., . . . HPTN 052 Study Team. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med, 365(6), 493-505.

9 Gardner, E. M., McLees, M. P., Steiner, J. F., del Rio, C., and Burman, W. J. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis, 52(6), 793-800.

10 Skarbinski, J., Rosenberg, E., Paz-Bailey, G., Hall, H. I., Rose, C. E., Viall, A. H., . . . Mermin, J. H. (2015). Human immunodeficiency virus transmission at each step of the care continuum in the United States. JAMA Intern Med. doi: 10.1001/jamainternmed.2014.8180.

11 Hall, H. I., Holtgrave, D. R., & Maulsby, C. (2012). HIV transmission rates from persons living with HIV who are aware and unaware of their infection. AIDS, 26(7), 893-896.

12 Marks, G., Crepaz, N., & Janssen, R. S., (2006). Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS, 20(10), 1447-1450.

13 Marks, G., Crepaz, N., Senterfitt, J. W., & Janssen, R. S. (2005). Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: Implications for HIV prevention programs. J Acquir Immune Defic Syndr, 39(4), 446-453.

14 Chen, M., Rhodes, P. H., Hall, H. I., Kilmarx, P. H., Branson, B. M., & Valleroy, L. A. (2012). Prevalence of undiagnosed HIV infection among persons aged ≥13 years — National HIV surveillance system, United States, 2005–2008. MMWR, 61(02), 57-64.

15 Wallace, M. & Nelson, T. (2014). Indianapolis TGA FY 2015 Ryan White Part A HIV Emergency Relief Grant Program – Attachment 5: Co-Morbidities, Cost, and Complexity Table, Indianapolis TGA. Available from Ryan White Services Program, Marion County Public Health Department.

16 Centers for Disease Control and Prevention, Health Resources and Services Administration, National Institutes of Health, & HIV Medicine Association of the Infectious Diseases Society of America. (2003). Incorporating HIV prevention into the medical care of persons living with HIV. MMWR, 52(RR12), 1-24.

17 Centers for Disease Control and Prevention. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR, 55(RR14), 1-17.

18 U.S. Department of Health & Human Services. (2014). Increasing Access to HIV Care and Treatment.

19 Janssen, R. S., Holtgrave, D. R., Valdiserri, R. O., Shepherd, M., Gayle, H. D., & DeCock, K. M. (2001). The serostatus approach to fighting the HIV epidemic: Prevention strategies for infected individuals. Am J Public Health, 91(7), 1019-1024.

20 Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., & Clark, J. E. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR, 55(RR14), 1-17.

21 U.S. Preventive Services Task Force. (2013). Final Recommendation Statement: Human Immunodeficiency Virus (HIV) Infection: Screening.