Vol. 2 No. 5 | HIV Surveillance Data Tables | Reports | Resource Library | HIV/AIDS

Technical Notes

The Ending the HIV Epidemic in the U.S. (EHE) ini­tiative leverages critical scientific advances in HIV prevention, diagnosis, treatment, and outbreak response [1]. The goal of the initiative is to reduce new HIV infections by 75% by 2025 and then by at least 90% by 2030. The Centers for Disease Control and Prevention (CDC) routinely releases HIV Surveil­lance Data Tables on the core indicators for EHE to allow for more timely monitoring of progress. The full list of EHE core indicators and their definitions can be found in the Technical Notes of the Core Indi­cators for Monitoring the Ending the HIV Epidemic Initiative report at https://www.cdc.gov/hiv/pdf/library/reports/surveillance-data-tables/vol-1-no-1/cdc-hiv-surveillance-tables-vol-1-no-1.pdf pdf icon[PDF – 1 MB].

The tables included in this report provide prelimi­nary data on HIV diagnoses and linkage to HIV medi­cal care reported to CDC as of September 2021 for the years 2020 and 2021, and data on preexposure prophy­laxis (PrEP) coverage for the years 2019, 2020, and 2021 (preliminary). Data for the 3 indicators are provided at the national, state, and county levels (EHE Phase I jurisdictions only). See Tabulation and Presentation of Data for details on how the indicators are calculated.

Tabulation and Presentation of Data

Diagnoses of HIV Infection

Diagnoses of HIV infection are the numbers of per­sons aged ≥ 13 years with HIV diagnosed during Janu­ary 2020 through September 2021 (Tables 1a–d). Data presented were reported (after the removal of person­ally identifiable information) to CDC.

An evaluation of surveillance data (2011–2015 diagnoses) found that, on average, approximately 75% of HIV diagnoses are reported to CDC during the year of diagnosis and approximately 95% of HIV diagnoses are reported to CDC by the end of the fol­lowing year. Data reported to CDC’s National HIV Sur­veillance System (NHSS) are considered preliminary until a 12-month reporting lag has been reached and should be interpreted with caution. In addition to being preliminary, data for years 2020 and 2021 should be interpreted with caution due to the impact of the COVID-19 pandemic on access to HIV testing, care-related services, and case surveillance activities in state/local jurisdictions [2].

More information on counting diagnoses of HIV infection can be found at https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-32/index.html (HIV Surveillance Report, 2019).

Linkage to HIV Medical Care

Linkage to HIV medical care within 1 month of HIV diagnosis is measured for persons aged ≥ 13 years whose infection was diagnosed during January 2020 through June 2021, and who resided in any of the jurisdictions (including EHE Phase I jurisdictions) with complete reporting of labo­ratory data to CDC at the time of diagnosis (Tables 2a–c). The numerator is the number of persons aged ≥ 13 years whose HIV infection was diagnosed during January 2020 through June 2021 and who had ≥ 1 CD4 T-lymphocyte (CD4) or viral load (VL) tests within 1 month of HIV diagno­sis. The denominator is the number of persons aged ≥ 13 years whose HIV infection was diagnosed during January 2020 through June 2021. Reporting of linkage to HIV medical care data requires a minimum 3-month reporting lag to account for delays in reporting of laboratory results to NHSS; therefore, data on linkage to HIV medical care in these surveillance tables are for persons with HIV diagnosed during 2020 and 2021 and that were reported to NHSS through September 2021. Data are not provided for states and associated jurisdictions that do not have laws requiring reporting of all CD4 and viral loads, or that have incomplete reporting of laboratory data to CDC. Areas without laws: Idaho and New Jersey. Areas with incomplete reporting: Kansas, Kentucky, Pennsylvania, Puerto Rico, and Vermont.

Data reported to NHSS are considered preliminary until a 12-month reporting lag has been reached and should be interpreted with caution. In addition to being preliminary, data for years 2020 and 2021 should be interpreted with caution due to the impact of the COVID-19 pandemic on access to HIV testing, care-related services, and case surveillance activities in state/local jurisdictions [2].

More information on calculating linkage to care can be found at (Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2019) pdf icon[PDF – 17 MB].

Preexposure Prophylaxis (PrEP) Coverage

Preexposure prophylaxis (PrEP) coverage, reported as a percentage, is defined as the number of persons aged ≥ 16 years classified as having been prescribed PrEP during the specified year divided by the estimated number of persons aged ≥ 16 years who had indications for PrEP during the speci­fied year (Tables 3a–3c). PrEP coverage is an EHE indicator that is not a reportable disease or condition and is not reported to NHSS. Multiple data sources, described below, are used to calculate PrEP coverage.

Please use caution when interpreting PrEP data. Different data sources were used in the numerator and denominator to calculate PrEP coverage.

Persons with PrEP indications

National pharmacy data from the IQVIA Real World Data—Longitudinal Prescriptions database (hereafter, IQVIA database) are used to classify persons aged ≥ 16 years who have been prescribed PrEP in the spe­cific year. The IQVIA database captures prescriptions from all payers and represents approximately 92% of all prescriptions from retail pharmacies and 60%–86% from mail-order outlets in the United States. The database does not include prescriptions from some closed health care systems that do not make their pre­scription data available to IQVIA. Therefore, these are minimum estimates of PrEP coverage. The annual number of persons classified as having been pre­scribed PrEP was based on a validated algorithm that discerns whether tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) was prescribed for PrEP after excluding prescriptions for HIV treatment, hepa­titis B treatment, or HIV postexposure prophylaxis [3–5]. Tenofovir alafenamide and emtricitabine (TAF/FTC) was approved as an alternative drug for PrEP by the U.S. Food and Drug Administration (FDA) in October 2019. Starting with the 2019 data, TAF/FTC was included in the algorithm to classify the number of persons prescribed PrEP. In addition, generic TDF/FTC for PrEP became available in the United States in October 2020. Starting with the 2020 data, generic TDF/FTC was included in the algorithm to classify the number of persons prescribed PrEP.

The number of persons classified as having been prescribed PrEP is reported by sex, age group, and race/ethnicity. Transmission category data are not available in the IQVIA database, and race/ethnicity data are available for < 40% of persons with PrEP prescriptions. Please use caution when interpreting PrEP data by race/ethnicity. Race/ethnicity catego­ries available in the IQVIA database include White, Black/African American, Hispanic/Latino, and other. The number of persons prescribed PrEP for each racial/ethnic group presented in this report was extrapolated by applying the racial/ethnic distribu­tion of known records to those for which data on race/ethnicity were unknown.

Geographic Designations

In the IQVIA database, a person’s location is reported as a 3-digit ZIP code prefix (hereafter, ZIP3) assigned by the U.S. Postal Service. To estimate the number of persons prescribed PrEP at the state or county level, a probability-based approach is used to crosswalk between ZIP3s and states/counties by using data from (a) the U.S. Census Bureau’s American Community Survey (ACS) 5-year estimates by ZIP Code Tabulation Areas (ZCTAs) [6], and (b) the U.S Department of Housing and Urban Development’s ZIP Code Crosswalk Files [7]. Because of reliability concerns, subnational estimates of <40 are not included.

Persons with PrEP indications

The ACS and U.S. Census Bureau files were used to estimate the number of men who have sex with men (MSM) in a jurisdiction [8, 9]. Next, behavioral data from the National Health and Nutrition Examination Survey (NHANES) were used to estimate the proportion of HIV-negative MSM with indications for PrEP [10].

The number of HIV-negative MSM with indications for PrEP was multiplied by the ratio of percentage of diagnoses during the specified year attributed to other major transmission risk groups compared to the percentage among MSM in a given state or county. The estimated numbers of persons with indications for PrEP in the 3 major transmission risk groups (MSM, heterosexuals, persons who inject drugs) in each jurisdiction were then summed to yield a state- or county-specific estimate. State estimates were then summed for a national total of persons with indications for PrEP [8]. Jurisdictional estimates were rounded to the nearest 10.

The tables included in this report provide updated data on PrEP coverage for the years 2019 through June 2021 by using the IQVIA data reported through June 2021. IQVIA conducts data quality assurance activities. As a result, the number of persons classified as having been prescribed PrEP in a given year might change from time to time. The impact of the changes may vary by demographic category nationally and by jurisdiction. The data sources used to estimate the number of persons with indications for PrEP have different schedules of availability. Consequently, the availability of a denominator lags the availability of a numerator by approximately 1 year or more. PrEP coverage data with a lagged denominator are considered preliminary.

For this release of HIV Surveillance Data Tables, 2018 denominators were used for 2019, 2020, and 2021 PrEP coverage data; consequently, 2019 through June 2021 PrEP coverage data are considered preliminary. In addition to being preliminary, data for the year 2020 through June 2021 should be interpreted with caution and with an awareness of the impact of the COVID-19 pandemic on filling PrEP prescriptions in state/local jurisdictions.

More information on calculating PrEP coverage can be found at (Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2019).

References

1. HHS. What is Ending the HIV Epidemic in the U.S.? https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overviewexternal icon. Updated June 2, 2021. Accessed October 25, 2021.
2. CDC [Schuchat A, CDC COVID-19 Response Team]. Public health response to the initiation and spread of pandemic COVID-19 in the United States, February 24–April 21, 2020. MMWR 2020;69(18):551–556. doi:http://dx.doi.org/10.15585/mmwr.mm6918e2external icon
3. Wu H, Mendoza MC, Huang YA, Hayes T, Smith DK, Hoover KW. Uptake of HIV preexposure prophylaxis among commercially insured persons—United States, 2010–2014. Clin Infect Dis 2017; 64(2):144–149. doi:10.1093/cid/ciw701
4. CDC [Huang YA, Zhu W, Smith DK, Harris N, Hoover KW]. HIV preexposure prophylaxis, by race and ethnicity—United States, 2014–2016. MMWR 2018;67(41):1147–1150. doi:10.15585/mmwr.mm6741a3
5. Furukawa NW, Smith DK, Gonzalez CJ, et al. Evaluation of algorithms used for PrEP surveillance using a reference population from New York City, July 2016– June 2018. Public Health Rep 2020;135(2):202–210. doi:10.1177/0033354920904085
6. U.S. Census Bureau. American Community Survey 5- year data (2009–2019). https://www.census.gov/data/developers/data-sets/acs-5year.2019.htmlexternal icon. Published December 10, 2020. Accessed October 25, 2021.
7. U.S. Department of Housing and Urban Development (HUD). HUD USPS ZIP code crosswalk files. https://www.huduser.gov/portal/datasets/usps_crosswalk.htmlexternal icon. Updated June 2021. Accessed October 25, 2021.
8. Grey JA, Bernstein KT, Sullivan PS, Purcell DW, Chesson HW, Gift TL, Rosenberg ES. Estimating the population sizes of men who have sex with men in US states and counties using data from the American Community Survey. JMIR public health and surveillance. 2016;2(1):e14.
9. Purcell DW, Johnson CH, Lansky A, Prejean J, Stein R, Denning P, et al. Estimating the population size of men who have sex with men in the United States to obtain HIV and syphilis rates. Open AIDS J 2012;6:98-107.
10. CDC [Smith DK, Van Handel M, Wolitski RJ, et al]. Vital Signs: Estimated percentages and numbers of adults with indications for preexposure prophylaxis to prevent HIV acquisition—United States, 2015. MMWR 2015;64(46):1291–1295. doi:10.15585/mmwr.mm6446a4

Suggested Citation

Centers for Disease Control and Prevention. Core indicators for monitoring the Ending the HIV Epidemic initiative (preliminary data): National HIV Surveillance System data reported through September 2021; and preexposure prophylaxis (PrEP) data reported through June 2021. HIV Surveillance Data Tables 2021;2(No. 5). https://www.cdc.gov/hiv/library/reports/surveillance-data-tables/index.html. Published December 2021. Accessed [date].

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Acknowledgments

HIV Surveillance Data Tables was prepared by the following staff and contractors of the Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC: Anna Satcher Johnson, Zanetta Gant, Ya-lin Huang, Dawn Smith, Jianmin Li, Xiaohong Hu, Baohua Wu, Kyung Lee, Weiming Zhu, Lei Yu, Norma Harris.

 Michael Friend and the Web and Consumer Services Team of the Prevention Communications Branch are acknowledged for editing and desktop publishing this report.

 Publication of HIV Surveillance Data Tables was made possible by the contributions of the state and territorial health departments and the HIV surveillance programs that provided surveillance data to CDC.