Source: Samir Parmar, MPH, HIV & Opioid Epidemiologist at Marion County Public Health Department

Introduction

The Marion County Public Health Department’s Ryan White HIV Services Program (RWSP) manages Part A, Minority AIDS Initiative (MAI), and Part C funding to address the needs of people living with HIV/AIDS (PLWH) in central Indiana, including those out of care or historically underserved or uninsured. The RSWP has received Part C funding since 1991, and Part A/MAI funding since 2007. The program helps out-of-care clients gain access to points of entry, provides a comprehensive HIV continuum of care, and complies with the National HIV/AIDS Strategy (NHAS). [1] The program works in the Ryan White Part A transitional grant area (TGA). TGA counties include Boone, Brown, Hamilton, Hancock, Hendricks, Johnson, Marion, Morgan, Putnam, and Shelby County.  Rates are calculated per 100,000 residents at risk. This analysis looks at HIV in Marion County.

The primary goal of this summary is to provide a brief summary on the latest HIV diagnoses and outcomes among women in Marion County.

Women Living with HIV in Marion County

The estimated total population for Marion County in 2018 was 955,110 people. In 2018, there were 204 new HIV diagnoses at a rate of 21.5 (95% CI: 18.6-24.6). In comparison, the nationwide rate was 11.8 in 2017 and the rate for Indiana was 7.8 in 2017. [2] There were an estimated 5,217 people living with HIV/AIDS (PLWHA) in Marion County in 2018.

Among new diagnoses, 26% (N=53) were female at a rate of 10.7 (95% CI: 7.8-13.6). The majority of women newly diagnosed were Black. Black females represented 18.1% of all new HIV diagnoses at a rate of 25.7 (95% CI: 17.4-34). HIV incidence continues to be higher among racial/ethnic minorities than among whites in Marion County. Among PLWHA, 21% (N=1,089) were females living with HIV in Marion County at a rate of 220 (95% CI: 206.9-233.1). Black females represented 13.5% of all PLWHA at a rate of 487.8 (95% CI: 451.7-523.9). Similar to incidence, HIV prevalence is higher among racial/ethnic minorities than Whites in Marion County.

The population attributable proportion (PAP) is helpful in quantifying the number of new HIV infections that might have been prevented in absence of racial disparities. [3,4] It can be used to describe the proportional decrease in HIV infection in HIV infection among black and white women combined that would be realized if the group with the higher rate had the same rate as did the group with the lower rate. [3] Combined black and white women made up the over 90% of new HIV diagnoses among women. A PAP of 0.36 was estimated for 2018 among black and white women, suggesting if the incident rate for black women were the same as that of white women, the total new HIV infections among black and white women would have been approximately 36% lower in 2018. An estimated 18 of 53 (33.9%) of new HIV infections among all women would not have occurred if rates were same for black and white women in Marion County for 2018.

Linkage to care among females is higher than that among males. In 2018, 71% of females were newly diagnosed within 30 days compared to 67.5% of males. However, 21% of females had a late diagnosis of HIV at AIDS in 2018 compared to 18.5% of males. 76% of women living with HIV received a CD4/viral load test during 2018. Only 56% of women were retained in care (2 or more CD4/VL tests at least 3 months apart). 62.2% of all women living with HIV are virally suppressed (<200 copies/ML) in Marion County, based on their last viral load result during the year.

Discussion and Major Takeaways

Women in Marion County are more likely to have late diagnosis than males. After diagnosis, retention in care and viral suppression among women present opportunities for major improvement. Understanding HIV diagnosis and continuum of care trends among women is vital to improving HIV prevention and HIV health outcomes in Marion County. An estimated 1 in 9 women living with HIV are unaware that they have it. [5] Most infections among women occur through heterosexual transmission. It is essential that women at high risk, such as those with multiple sex partners, those who exchange sex for drugs/money, those having sex without a condom, or those with incomplete knowledge of male partner’s risk factors for HIV, get tested.

The trend in Marion County is similar to the national trend, with HIV infection rates among black women much higher than rates among white women. Nationally, an estimated 3900 of 4,200 (93%) incident HIV infections among black women would not have occurred if HIV incident rates were the same for black and white women in 2016 [3].

As CDC highlights in recent work, targeted measures to reduce transmission through viral suppression and prevention through PrEP and condom use are very important to reducing disparities. [3] However, increased public health efforts are needed to identify and address social and structural determinants associated with these HIV health disparities among black women. [3] Additionally, providers should consider health problems unique to women living with HIV that interfere with goals of viral suppression and general wellbeing, such as a variety of gynecological problems, cervical cancer risk, HIV medicine side effects unique to women, younger menopause, and increased risk of osteoporosis among older women. [6, 7] HIV.gov and Womenshealth.gov have developed materials highlighting these unique health issues that women living with HIV face. [6, 7]

Sources

[1] White House Office of National AIDS Policy (2015). National HIV/AIDS strategy for the United States: Updated to 2020. https://www.hiv.gov/federal-response/national-hiv-aids-strategy/nhas-update

[2] Centers for Disease Control and Prevention (2018). HIV surveillance report, 2017; Vol. 29. Retrieved from https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2017-vol-29.pdf

[3] Centers for Disease Control and Prevention (2019). Disparities in Incidence of Human Immunodeficiency Virus Infection Among Black and White Women — United States, 2010–2016. Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/mm6818a3.htm?s_cid=mm6818a3_e

[4] Erin et al. (2018). Trends in selected measures of racial and ethnic disparities in gonorrhea and syphilis in the United States, 1981–2013. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5905678/

[5] Centers for Disease Control and Prevention (2019). HIV Among Women. Retrieved from https://www.cdc.gov/hiv/group/gender/women/index.html

[6] HIV.gov (2019). HIV and Women’s Health Issues. Retrieved from https://www.hiv.gov/hiv-basics/staying-in-hiv-care/other-related-health-issues/womens-health-issues [7] Womenshealth.gov (2019). HIV and women’s health. Retrieved from https://www.womenshealth.gov/hiv-and-aids/living-hiv/hiv-and-womens-health