2020 HIV Surveillance Proves Earlier COVID-19 Concerns

On May 24th, the U.S. Centers for Disease Control and Prevention (CDC) issued its much anticipated annual HIV surveillance report. The anticipation is akin to waiting for a bill in the mail, “how bad is it gonna be?” In the same vein as this sentiment is the understanding that we, as a country, made the policy decisions to underinvest in public health programs, the political calculus in response to a public health emergency, and the diversion of already too scarce personnel and infrastructure resources in HIV in the effort to address COVID-19. We’re reminded of this shifting of costs, “robbing Peter to pay Paul”, throughout the annual report, in every infographic, and in the press releases associated with the report’s announcement: “Data for 2020 should be interpreted with caution due to the impact of the COVID-19 pandemic.”

Source: CDC. Diagnoses of HIV infection in the United States and dependent areas, 2020. HIV Surveillance Report 2021;33; retrieved online at: https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-33/index.html

The top line of the report is a marked decrease in new HIV diagnoses; where since 2016, we’ve typically seem about a 3% annual decrease in new diagnoses, 2020 gave us a 17% decrease. The aforementioned press release states the decline in new diagnoses should be “attributed to declines in testing caused by less frequent visits to health centers, reduced outreach services, and shifting of public health staff to COVID-19 response activities.” The press release went further, remarking that because COVID-19 is “still ongoing, more time and data are needed to accurately assess COVID-19’s impact on HIV” and urged those relying on these data to not provide assessment s on trends in HIV diagnoses to include 2020 data are a result. A noted difference from traditional reports, this year’s supplemental Estimated HIV Incidence and Prevalence in the U.S. will not be published.

Another finding in the report is the rate of death for people with an HIV diagnosis. While the report appropriately notes the data is “all cause” deaths among people living with HIV and those deaths should not necessarily be attributed to an HIV-related complication, the incidence of death among people living with HIV did increase in 2020 significantly. This particular data category is one the CDC notes should not be “assessed” as misinterpretation is distinctly possible, if not likely. With more than one million dead from COVID-19 in the United States, HIV will not be an outlier in seeing increased all cause mortality. However, this data should be closely watched given our aging patient population and the high correlation between COVID-19 mortality risks and age.

The report encourages viewers to access the CDC’s data tool, Atlas Plus, to review “Stage 3” (AIDS) classification and prevalence. The data table for this shows a similar marked decrease in providers classifying patients living with HIV with advanced conditions and AIDS-defining diagnoses, compared to similar years. However, that decrease should be viewed extreme caution as data on linkage to and retention in care is not yet available. As NBC’s, Benjamin Ryan reported, some providers who saw patients drop out of care during the height of COVID-19-related restrictions and are now seeing patients return to care “devastatingly ill with multiple AIDS-defining diagnoses”.

A final note on the data provided, Black gay and bisexual and other men who have sex with men, Black women, and Black transgender people remain a patient demographic hard hit by new HIV diagnoses. The South accounts for nearly half of all new diagnoses. These things are not coincidental. While expanding Medicaid in southern states would provide additional opportunities for communities to find health care coverage, a lack of Medicaid expansion does not explain these geographic and demographic disparities. It is important to always recall the vast majority of the Black people living in the United States also happen to live in southern states – ultimately, racism, while hard to “measure” in a public health context, cannot be dismissed or overcome by the limited imagination of expanding Medicaid. Medicaid expansion would well-serve southern states and provide an excellent tool but should not be considered the only tool or surest answer to the social ills inflicting harm on southern Black communities.

Supplemental reports are published throughout the year, helping to further define the contours of the domestic epidemic. We’ll be monitoring and evaluating the data from these as they’re published and encourage stakeholders to review these data, weighing how best to support public health programs aimed at addressing HIV and the health and social disparities that drive the epidemic. As always, pertinent data monitoring public health programs serving at the intersection of HIV and Hepatitis C can be found in Community Access National Network’s quarterly HIV-HCV Coinfection Watch.

In multiple previous blogs throughout 2021 and during both the 2021 and 2022 Community Roundtable events, I’ve stressed the issue of “flying blind” as a result of losing hard earned ground with regard to regular testing, linkage to care, and engagement in care. The 2020 surveillance unfortunately proves this point and, as the CDC has noted, the COVID-19 pandemic is still ongoing. I’d go further and state the disruptions caused by the COVID-19 pandemic are also still ongoing. While many public health programs are working to recover personnel shifts, some state legislatures are cutting funding for health departments. Yes, activities associated with HIV programs are generally federally funded and administrative supports necessary to hire and train sufficient personnel are tied to broader public health programming and if these jobs aren’t filled, then the jobs associated with HIV programming may well go unfilled as well. Stakeholders will need to keep an eye on the evolution of data as we begin to uncover just how much COVID-19 has cost us in HIV progress.