Vol. 4 No. 1 | 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 included tables provide national-, state-, and county-level (EHE Phase I jurisdictions only; see Table 7) data for the 6 core indicators of the EHE initiative, which are the following:

• New HIV infections: the estimated number of new HIV infections in a calendar year.
• Knowledge of HIV status: the estimated percentage of persons with HIV who have received a diagnosis.
• Diagnoses of HIV infection: the number of HIV infections confirmed by laboratory or clinical evidence in a calendar year.
• Linkage to HIV medical care: the percentage of persons who have received a diagnosis of HIV infection in a calendar year and were linked to HIV medical care within 1 month.
• HIV viral suppression: the percentage of persons living with diagnosed HIV who have a suppressed viral load at the most recent test in a calendar year.
• Preexposure prophylaxis (PrEP) coverage: the percentage of the number of persons prescribed PrEP in a calendar year relative to the estimated number of persons with indications for PrEP in a calendar year.

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.

Surveillance of HIV Infection

Data presented were reported (after the removal of personally identifiable information) to the CDC through December 31, 2022. Please use caution when interpreting the following:

• Data for the year 2020. 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. [2–6].
• Data for the year 2022. Data provided using a National HIV Surveillance System (NHSS) dataset produced prior to reaching a 12-month reporting lag are considered preliminary.
• HIV incidence and prevalence estimates. Estimates for years 2020 and 2021 should be interpreted with caution due to adjustments made to the CD4+ T-lymphocyte (CD4)-based depletion model [7] to account for the impact of COVID-19 on HIV testing and diagnosis in the United States. The original CD4-based model assumes stable testing and diagnosis trends during the period assessed. However, the COVID-19 pandemic caused both HIV testing [5, 6] and HIV diagnoses [8, 9] to deviate from recent trends. The monthly distribution of diagnoses occurring during 2020 and 2021 were adjusted to account for excess delay. See the Technical Notes of Estimated HIV incidence and prevalence in the United States, 2017–2021 at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html for additional information.
• Data on diagnoses of HIV infection. HIV surveillance reports may not be representative of all persons with HIV because not all infected persons have been (1) tested or (2) tested at a time when the infection could be detected and diagnosed. Also, some states offer anonymous HIV testing; the results of anonymous tests are not reported to the confidential, name-based HIV registries of state and local health departments. Therefore, reports of confidential test results may not represent all persons who tested positive for HIV infection.
• Deaths and prevalence-based data (HIV viral suppression) due to known delays in reporting of deaths to CDC.
• Numbers less than 12 and trends based on these numbers.

Tabulation and Presentation of Data

New HIV Infections (HIV Incidence)

New HIV infections among persons aged ≥ 13 years are estimated using the first CD4 test result after HIV diagnosis and a CD4-depletion model indicating disease progression or duration after infection (Tables 1a–c).

More information on estimating new HIV infections can be found at in the report Estimated HIV incidence and prevalence in the United States, 2017–2021 at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

Knowledge of HIV Status

The Knowledge of HIV Status indicator is measured as the percentage of persons aged ≥ 13 years with diagnosed HIV infection (Tables 2a–c). For this measure, the numerator (data reported to CDC) is the number of persons aged ≥ 13 years living with diagnosed HIV infection at the end of the year. The denominator, total HIV prevalence, is the estimated number of persons aged ≥13 years living with HIV infection (diagnosed or undiagnosed) at the end of the year. Knowledge of status and prevalence data for the year 2021 are preliminary and based on death data reported to CDC as of December 2022. The following areas had incomplete reporting of deaths for the year 2021, and prevalence estimates should be interpreted with caution: Mississippi. Estimates for areas without laws requiring reporting of laboratory data, or with incomplete reporting of laboratory data to CDC, should also be interpreted with caution. Areas without laws: Idaho. Areas with incomplete reporting: New Jersey, Pennsylvania (excluding Philadelphia County), and Puerto Rico.

More information on calculating HIV prevalence and percentage of persons with diagnosed HIV infection can be found in the report Estimated HIV incidence and prevalence in the United States, 2017–2021 at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

Diagnoses of HIV Infection

Diagnoses of HIV infection are the numbers of persons aged ≥ 13 years with HIV diagnosed during 2017–2022 (Tables 3a–d). Data presented were reported (after the removal of personally identifiable information) to CDC.

An evaluation of surveillance data (2016–2020 diagnoses) found that, on average, approximately 80% of HIV diagnoses are reported to CDC during the year of diagnosis and approximately 98% of HIV diagnoses are reported to CDC by the end of the following year. Data for the year 2022 are considered preliminary until a 12-month reporting delay has been reached and should be interpreted with caution.

More information on counting diagnoses of HIV infection can be found in the HIV Surveillance Report, 2021 at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

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 2021 through September 2022 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 4a–c). The numerator is the number of persons aged ≥ 13 years whose HIV infection was diagnosed during January 2021 through September 2022 and who had ≥ 1 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 2021 through September 2022. Reporting of linkage to HIV medical care data requires a minimum 3-month reporting delay 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 January 2021 through September 2022 and reported to NHSS through December 2022. Data are not provided for states and associated areas 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. Areas with incomplete reporting: New Jersey, Pennsylvania (excluding Philadelphia County, and Puerto Rico.

More information on calculating linkage to care can be found at in the report Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2021 at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

HIV Viral Suppression

Viral suppression at most recent test during 2021 is measured for persons aged ≥ 13 years who resided, as of their most recent known address during 2021, in any of the jurisdictions (including EHE Phase I jurisdictions) with complete reporting of laboratory data to CDC and who were alive at the end of 2021 (Tables 5a–c). The numerator is the number of persons aged ≥ 13 years with HIV infection diagnosed by the end of 2020 and who had a VL of < 200 copies/mL at the most recent test in 2021. The denominator is the number of persons aged ≥ 13 years with HIV diagnosed by the end of 2020 and who were alive at the end of 2021. Data used to calculate prevalence are based on deaths reported to CDC as of December 2022. The following areas had incomplete reporting of deaths for the year 2021, and viral suppression data should be interpreted with caution: Mississippi. Data are not provided for states and associated areas 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. Areas with incomplete reporting: New Jersey, Pennsylvania (excluding Philadelphia County), and Puerto Rico.

More information on calculating viral suppression can be found in the report Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2021 at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.

Preexposure Prophylaxis (PrEP) Coverage

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 6a–c). 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 prescribed PrEP

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 93% of all prescriptions from retail pharmacies and 77% 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 [10–12]. 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. Long-acting injectable cabotegravir (CAB-LA) was approved by the FDA as an additional prevention option for PrEP in December 2021. TAF/FTC and injectable cabotegravir were included in the algorithm after their approval 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) [13], and (b) the U.S Department of Housing and Urban Development’s ZIP Code Crosswalk Files [14]. Because of reliability concerns, subnational estimates of < 40 are not included.

Persons with PrEP indications

U.S. Census Bureau files and their ACS were used to estimate the number of men who have sex with men (MSM) in a jurisdiction [15, 16]. 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 [17].

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 [15]. Jurisdictional estimates were rounded to the nearest 10.

The tables included in this report provide updated data on PrEP coverage for the years January 2017–September 2022 by using the IQVIA data reported through September 2022. 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. 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, 2021, and 2022 PrEP coverage data; consequently, 2019 through September 2022 PrEP coverage data are considered preliminary. In addition to being preliminary, data for the year 2020 should be interpreted with awareness of the impact of the COVID-19 pandemic on filling PrEP prescriptions in state/local jurisdictions [18].

More information on calculating PrEP coverage can be found in the report Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2021 at https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html

References

1. HHS. What is Ending the HIV Epidemic in the U.S.? https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview. Updated July 2, 2022. Accessed March 13, 2023.
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.mm6918e2
3. Delaney KP, Jayanthi P, Emerson B, et al. Impact of COVID-19 on commercial laboratory testing for HIV in the United States. 2021 CROI, March 6–10, 2021. Abstract 739.
4. Moitra E, Tao J, Olsen J, et al. Impact of the COVID-19 pandemic on HIV testing rates across four geographically diverse urban centres in the United States: an observational study. Lancet Reg Health Am 2022;7:100159. doi:10.1016/j.lana.2021.100159
5. Chang JJ, Chen Q, Hechter RC, Dionne-Odom J, Bruxvoort K. Changes in HIV and STI testing and diagnoses during the COVID-19 pandemic. 2022 CROI, February 12–16 and 22–24, 2022. Oral Abstract 142.
6. DiNenno EA, Delaney KP, Pitasi MA, et al. HIV testing before and during the COVID-19 pandemic—United States, 2019–2020. MMWR 2022;71(25):820–824. doi:10.15585/mmwr.mm7125a2. PMID: 35737573
7. Song R, Hall HI, Green TA, Szwarcwald CL, Pantazis N. Using CD4 data to estimate HIV incidence, prevalence, and percent of undiagnosed infections in the United States. J Acquir Immune Defic Syndr 2017;74(1):3–9. doi:10.1097/QAI.0000000000001151
8. CDC. HIV Surveillance Report, 2020; vol. 33. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published May 2022. Accessed March 13, 2023.
9. Viguerie A, Song R, Johnson AS, Lyles CM, Hernandez A, Farnham PG. Isolating the effect of COVID-19–related disruptions on HIV diagnoses in the United States in 2020. J Acquir Immune Defic Syndr 2023;92(4):293–299. doi:10.1097/QAI.0000000000003140
10. 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
11. 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
12. 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
13. U.S. Census Bureau. American Community Survey 5-year data (2009–2021). https://www.census.gov/data/developers/data-sets/acs-5year.2019.html. Published December 2022. Accessed March 13, 2023.
14. U.S. Department of Housing and Urban Development (HUD). HUD USPS ZIP code crosswalk files. https://www.huduser.gov/portal/datasets/usps_crosswalk.html. Updated August 2022. Accessed March 13, 2023.
15. Grey JA, Bernstein KT, Sullivan PS, et al. 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 Surveill 2016;2(1):e14. doi:10.2196/publichealth.5365
16. Purcell DW, Johnson CH, Lansky A, 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. doi:10.2174/1874613601206010098
17. 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
18. Huang YA, Zhu W, Wiener J, Kourtis AP, Hall HI, Hoover KW. Impact of COVID-19 on HIV preexposure prophylaxis prescriptions in the United States—a time series analysis. Clin Infect Dis 2022:ciac038. doi:10.1093/cid/ciac038

Suggested Citation

Centers for Disease Control and Prevention. Core indicators for monitoring the Ending the HIV Epidemic initiative: National HIV Surveillance System data reported through December 2022; and preexposure prophylaxis (PrEP) data reported through September 2022. HIV Surveillance Data Tables 2022;3(4). https://www.cdc.gov/hiv/library/reports/surveillance-data-tables/. Published May 2023. Accessed [date].

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Acknowledgments

This issue of 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, Weiming Zhu, Ruiguang Song, Baohua Wu, Sue Reynolds, Jianmin Li, Xiaohong Hu, Pei Hou, Emily Zhu, Lei Yu, Avery Smithson, Wei Wei, Iddrisu Abdallah, Juliet Morales, Anna Baker, Andre Dailey, Shacara Johnson Lyons, Alex Viguerie, Norma Harris, Stacy Cohen, and Michael Friend (editing and desktop publishing).

The Web and Consumer Services Team of the Prevention Communications Branch are acknowledged for their contributions to the report website.

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.