Trends in HIV Care Outcomes Among Black and Non-Black Females in 41 US Jurisdictions,2017-2021

Abstract

Objectives:

From 2017 through 2021, the rate of HIV diagnoses among females aged ≥13 years declined by 12%. Despite efforts to reduce HIV infections, disparities persist. To understand and address differential health outcomes, the present study examined trends among non-Hispanic Black/African American and non-Black/African American females in the United States.

Methods:

Using data from the Centers for Disease Control and Prevention’s National HIV Surveillance System, we summarized HIV diagnoses and percentage distributions for linkage to HIV medical care within 1 month of diagnosis and viral suppression within 6 months of diagnosis among females aged ≥13 years in 41 US jurisdictions. We analyzed trends for non-Hispanic Black and non-Black (defined as all other races and ethnicities) females with HIV diagnosed from 2017 through 2021 (excluding 2020) by age, transmission category, region, and jurisdiction of residence using estimated annual percentage change. A trend was considered stable when the 95% CI for estimated annual percentage change included zero.

Results:

From 2017 through 2021, 16 514 non-Hispanic Black females and 12 711 non-Black females received an HIV diagnosis. During these years, the rate of HIV diagnoses for non-Hispanic Black females decreased by 5.3%, linkage to care increased by 1.5%, and viral suppression increased by 1.6% per year, on average. For non-Black females, the rate of HIV diagnoses was stable, linkage to care increased by 0.8%, and viral suppression increased by 1.4% per year, on average.

Conclusions:

Our findings highlight a decline in HIV diagnoses among non-Hispanic Black females with some improvement in HIV care outcomes. However, more efforts are needed to increase access to treatment and care services that are essential for improving health outcomes among adolescents and adult females, particularly those disproportionately affected by HIV.

Keywords

HIV care linkage to HIV care HIV viral suppression Ending the HIV Epidemic EHE

The annual rate of HIV diagnoses among females aged ≥13 years in the United States decreased by 12% overall and by 19% among non-Hispanic Black or African American (hereinafter referred to as Black) females in 2021 compared with 2017.¹ Although progress has been made toward improving HIV outcomes among females, differences in HIV diagnosis, treatment, and care outcomes persist among subpopulations of females in the United States.^2-4 In 2021, Black females accounted for 54% of 6584 HIV diagnoses among all females, indicating that Black females continue to be disproportionately affected by HIV.¹

Socioeconomic factors, including access to health care, have long been associated with high rates of HIV diagnoses and poor HIV care outcomes.^5,6 Receipt of care was approximately 74% and viral suppression slightly higher than 62% among Black females in 2021.⁷ Competing demands, such as lack of social support, transportation barriers, financial instability, and employment status, have further affected retention in care and adherence to antiretroviral therapy for sustained viral suppression.^8,9 Because of pay inequities, females are more likely to earn less than males and are therefore more likely than males to live in poverty, lack health insurance or have inadequate health insurance, and have high health care costs.^10-12 Health insurance access to preventive care and medications may still be limited or delayed as a result of the out-of-pocket expenses associated with these services,¹² and such limitations could also lead to poor health outcomes for females living with HIV.

Monitoring HIV-related health outcomes is important for understanding and alleviating differential health effects and reaching national HIV prevention and care goals for females in the United States.¹³ In this study, we assessed trends in HIV diagnosis, linkage to care within 1 month of HIV diagnosis, and viral suppression within 6 months of diagnosis among Black females and females of all other races and ethnicities (hereinafter, non-Black females) from 2017 through 2021.

Methods

Surveillance programs of state, territorial, local, and tribal (STLT) health departments routinely gather information for monitoring cases of HIV infection and report data to the Centers for Disease Control and Prevention (CDC). To characterize trends in HIV diagnoses, linkage to HIV medical care within 1 month of diagnosis, and viral suppression within 6 months of diagnosis among Black and non-Black females aged ≥13 years in 41 jurisdictions, we analyzed data on HIV cases diagnosed from 2017 through 2021 and reported to CDC’s National HIV Surveillance System (NHSS) as of December 2022. National and state-level data for years 2010 through 2022 are available via the National Center for HIV, Viral Hepatitis, STD, and TB Prevention AtlasPlus.¹⁴ We limited our analysis to 41 jurisdictions with mandatory and complete laboratory reporting of CD4+ T-lymphocyte count (CD4) and viral load test results each year during the study period. The 41 jurisdictions were Alabama, Alaska, California, Colorado, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, Wyoming, and the District of Columbia. STLT health departments deidentified and deduplicated the data upon submission. In accordance with federal guidelines (eg, 45 CFR part 46.102[I][2]; 21 CFR part 56; 42 USC §241[d]; 5 USC §552a; 44 USC §3501 et seq), surveillance of cases of HIV infection is determined to be a public health activity and not human subjects research, and ethical consideration and institutional review board approval are not required for analyses or reporting of NHSS data. Thus, we did not seek institutional review board approval for this work.

NHSS is a population-based census of people in the United States and 6 US territories and freely associated states who have received an HIV diagnosis, with completeness of reporting estimated to be at least 85% as of December 2021.¹⁵ STLT health departments report demographic, clinical, and risk information on people with HIV. STLT health departments assign reported cases to their jurisdiction or state of residence at the time of HIV diagnosis. STLT health departments also collect race and ethnicity data, which are reported to CDC in accordance with the Office of Management and Budget standards.¹⁶ As mentioned, females reported as any race or ethnicity other than Black were grouped as non-Black females. The transmission category represents the risk factor by which a person most likely acquired HIV (injection drug use, heterosexual contact, or other). We used multiple imputation to assign the transmission category for cases of HIV infection without an identified risk factor.¹⁷ We indicated linkage to HIV medical care as documentation of at least 1 CD4 or viral load test within 1 month of HIV diagnosis. We indicated viral suppression as documentation of a viral load test result of <200 copies/mL within 6 months of HIV diagnosis.

Analyses

We calculated the estimated annual percentage change (EAPC) and 95% CIs to assess trends during 2017 through 2021 (we excluded 2020, as no such linear interpolation was applied to this year) for HIV diagnoses, linkage to HIV medical care, and HIV viral suppression by age group, transmission category, jurisdiction of residence, and region of residence among Black and non-Black females. To assess trends in HIV diagnoses, we calculated EAPCs by using log-binomial regression based on the rate of HIV diagnoses. Rates were per 100 000 population. Otherwise, for transmission category, we calculated EAPCs by using Poisson regression on the number of diagnoses because of the lack of population denominators from the US Census Bureau. To assess trends for linkage to HIV medical care and viral suppression, we calculated EAPCs by using log-binomial regression based on percentage distributions. We did not calculate EAPCs for selected characteristics or jurisdictions with small case counts (≤12 y) in at least 4 of the 5 years (2017-2021). Data were not available or were suppressed for certain jurisdictions; suppression is in accordance with stratification levels approved by each jurisdiction under a data re-release agreement with CDC.

Due to the impact of the COVID-19 pandemic on access to HIV testing, care-related services, and case surveillance activities in state and local jurisdictions, we excluded 2020 data in the assessment of trends and based the estimated annual trends on 4 years of data. We used SAS version 9.4 (SAS Institute Inc) for data analyses and considered trends statistically significant (hereinafter, significant) when the 95% CI for EAPC excluded 0. Otherwise, we described trends that were not significant as stable.

Results

HIV Diagnoses

From 2017 through 2021 in the 41 jurisdictions, 16 514 Black females and 12 711 non-Black females received an HIV diagnosis. The rate of HIV diagnoses among Black females decreased by 5.3% (95% CI, −6.4 to −4.2) per year, whereas the rate of HIV diagnoses among non-Black females remained stable per year, on average (Figure 1, Table 1). By age group, the rate of diagnoses decreased significantly per year across all age groups, ranging from 3.5% (95% CI, −5.7 to −1.2) among Black females aged 35 to 44 years to 6.8% (95% CI, −9.3 to −4.1) among Black females aged ≥55 years per year, on average. The rate decreased by 4.3% (95% CI, −7.7 to −0.8) among non-Black females aged 13 to 24 years per year, on average, and were stable across all other age groups. By transmission category, the number of diagnoses among Black females with HIV infection attributed to heterosexual contact decreased by 4.7% (95% CI, −5.9 to −3.5) per year, on average, and was stable among non-Black females. Trends in the number of diagnoses among Black and non-Black females with HIV infection attributed to injection drug use or other risk factors, including hemophilia, blood transfusion, or a factor not identified, remained stable.

Figure 1.

Trends in rate (per 100 000 population) of HIV diagnoses among non-Hispanic Black/African American (indicated as Black) females and females of all other races and ethnicities (indicated as non-Black), 2017-2021 (excluding 2020), in 41 US jurisdictions. Jurisdictions included Alabama, Alaska, California, Colorado, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, Wyoming, and the District of Columbia. The estimated annual percentage change (EAPC) indicates the per-year percentage change, on average, in the rate of HIV diagnoses. The 95% CIs not including 0 indicate significant trends, whereas 95% CIs including 0 indicate no significant trend. Data source: Centers for Disease Control and Prevention.¹⁴

Table 1.

HIV diagnoses among females aged ≥13 years during 2017-2021, by selected characteristics, in 41 US jurisdictions^a

Characteristic	2017				2021				2017-2021 (excluding 2020)
	Black		Non-Black		Black		Non-Black		Black	Non-Black
	No.	Rate^b	No.	Rate^b	No.	Rate^b	No.	Rate^b	EAPC^c (95% CI)	EAPC^c (95% CI)
Age at diagnosis, y
13-24	549	17.2	364	2.0	432	13.7	305	1.6	−5.8^d (−8.7 to −2.9)	−4.3^d (−7.7 to −0.8)
25-34	1017	36.0	746	4.5	834	28.5	746	4.6	−5.5^d (−7.6 to −3.3)	0.2 (−2.2 to 2.6)
35-44	838	34.2	606	4.0	776	30.1	712	4.5	−3.5^d (−5.7 to −1.2)	2.4 (−0.2 to 5.1)
45-54	724	29.2	504	3.2	566	23.8	493	3.3	−5.0^d (−7.5 to −2.5)	0.2 (−2.7 to 3.2)
≥55	644	13.5	371	1.0	523	10.1	367	0.9	−6.8^d (−9.3 to −4.1)	−1.1 (−4.4 to 2.4)
Transmission category^e
Injection drug use^f	310		622		261		663		−3.4 (−9.0 to 2.5)	1.3 (−1.5 to 4.1)
Heterosexual contact^g	3436		1958		2843		1945		−4.7^d (−5.9 to −3.5)	−0.2 (−1.7 to 1.4)
Other^h	26		12		27		15		−2.1 (−18.8 to 18.1)	8.1 (−13.9 to 35.7)
Region of residence
Northeast	384	24.8	353	3.0	286	18.2	261	2.2	−7.5^d (−10.8 to −4.0)	−7.9^d (−11.4 to −4.3)
Midwest	557	18.9	360	1.4	462	15.3	407	1.6	−4.9^d (−7.7 to −2.0)	3.0 (−0.4 to 6.5)
South	2617	26.2	1331	3.3	2189	21.1	1380	3.4	−5.2^d (−6.5 to −3.9)	0.1 (−1.7 to 1.9)
West	214	17.5	547	2.1	194	15.7	575	2.1	−4.0 (−8.3 to 0.4)	0.7 (−2.1 to 3.5)
Jurisdiction of residence
Alabama	99	17.1	36	2.3	85	14.1	44	2.7	−3.8 (−10.3 to 3.1)	6.6 (−4.3 to 18.7)
Alaska	1	11.7	7	2.5	1	12.2	4	1.4	12.8 (−40.9 to 115.3)	−9.9 (−34.4 to 23.7)
California	142	14.8	402	2.6	129	13.6	425	2.7	−2.9 (−8.2 to 2.6)	1.2 (−2.1 to 4.5)
Colorado	15	17.7	26	1.1	14	15.5	39	1.7	0.7 (−14.6 to 18.8)	9.8 (−1.2 to 21.9)
Delaware	25	27.2	10	3.0	11	11.0	7	2.0	−19.5^d (−32.2 to −4.4)	−5.9 (−27.0 to 21.5)
District of Columbia	67	45.3	8	4.7	42	30.5	4	2.4	−9.6^d (−17.8 to −0.6)	−14.6 (−36.3 to 14.4)
Florida	611	43.9	374	4.8	499	34.3	328	4.0	−5.7^d (−8.4 to −2.9)	−3.6^d (−7.0 to −0.2)
Georgia	445	30.8	115	3.8	367	23.8	101	3.2	−6.2^d (−9.3 to −2.9)	−5.3 (−11.1 to 0.8)
Hawaii	0	0	6	1.0	2	23.1	9	1.5	—ⁱ	11.3 (−13.1 to 42.7)
Illinois	160	20.0	63	1.3	111	13.9	76	1.6	−8.9^d (−13.9 to −3.6)	5.5 (−2.1 to 13.7)
Indiana	52	19.7	55	2.1	60	21.5	47	1.8	1.6 (−7.1 to 11.0)	−5.6 (−14.2 to 3.8)
Iowa	13	32.2	11	0.9	9	19.6	17	1.3	−10.4 (−26.5 to 9.1)	5.4 (−10.7 to 24.3)
Louisiana	186	28.8	50	3.7	147	22.6	61	4.6	−6.6^d (−11.4 to −1.5)	2.6 (−6.1 to 12.0)
Maine	1	15.7	3	0.5	3	38.3	1	0.2	20.7 (−19.6 to 81.3)	−21.3 (−47.0 to 16.8)
Maryland	223	27.5	59	3.2	143	16.9	39	2.1	−11.5^d (−15.8 to −7.1)	−8.3 (−16.9 to 1.1)
Massachusetts	64	30.4	87	3.1	74	32.9	59	2.0	−0.7 (−8.1 to 7.4)	−10.6^d (−17.2 to −3.4)
Michigan	96	16.0	45	1.2	61	10.1	38	1.0	−11.6^d (−18.3 to −4.4)	−6.4 (−15.3 to 3.5)
Minnesota	51	39.8	21	1.0	35	23.4	29	1.3	−12.2^d (−21.3 to −2.1)	5.8 (−6.0 to 19.1)
Mississippi	89	18.3	19	2.4	82	16.8	31	3.9	−1.8 (−8.8 to 5.7)	11.2 (−2.4 to 26.6)
Missouri	69	22.6	32	1.4	50	16.2	53	2.3	−5.4 (−13.5 to 3.3)	13.9^d (3.0 to 26.1)
Montana	0	0	2	0.5	0	0	2	0.4	−36.9 (−88.1 to 234.4)	1.1 (−33.3 to 53.2)
Nebraska	6	17.5	9	1.2	5	13.7	13	1.7	1.5 (−23.3 to 34.3)	15.5 (−7.4 to 43.9)
New Hampshire^j	—	—	—	—	—	—	—	—	—	—
New Mexico	2	14.7	17	2.0	2	13.7	18	2.0	3.1 (−37.1 to 69.0)	0.4 (−13.5 to 16.6)
New York	311	23.9	247	3.4	206	15.8	188	2.5	−9.3^d (−13.1 to −5.4)	−6.7^d (−10.9 to −2.3)
North Carolina	177	17.9	75	2.2	165	16.2	83	2.3	−1.5 (−6.4 to 3.8)	1.0 (−6.2 to 8.8)
North Dakota	6	88.3	1	0.3	8	98.5	6	2.0	−1.6 (−22.4 to 24.7)	38.0 (−2.5 to 95.4)
Ohio	81	13.0	97	2.2	100	15.6	103	2.3	5.3 (−1.8 to 12.8)	2.2 (−4.3 to 9.2)
Oklahoma	25	21.1	26	1.7	25	20.6	44	2.8	6.2 (−8.3 to 23.1)	9.8 (−0.9 to 21.7)
Oregon	7	24.4	30	1.7	5	15.9	24	1.3	−8.9 (−35.9 to 29.5)	−8.4 (−20.0 to 4.9)
Rhode Island	8	31.0	8	1.8	3	10.5	8	1.7	−23.3 (−44.1 to 5.3)	−0.3 (−22.0 to 27.4)
South Carolina	93	15.5	66	4.1	78	12.8	64	3.8	−5.9 (−12.4 to 1.0)	−1.5 (−9.7 to 7.5)
South Dakota	3	57.7	6	1.7	1	16.0	5	1.4	−29.7 (−62.6 to 32.3)	0.5 (−24.2 to 33.2)
Tennessee	71	14.5	55	2.3	92	18.1	69	2.7	3.9 (−3.2 to 11.6)	7.3 (−1.4 to 16.9)
Texas	387	26.9	362	3.6	349	22.5	401	3.8	−4.0^d (−7.2 to −0.6)	0.7 (−2.6 to 4.2)
Utah	5	47.1	6	0.5	2	15.7	8	0.6	−23.4 (−49.0 to 15.1)	4.5 (−17.9 to 33.0)
Virginia	116	16.3	68	2.3	99	13.6	58	1.9	−5.5 (−11.3 to 0.6)	−2.6 (−11.0 to 6.6)
Washington	42	39.8	50	1.7	39	33.2	45	1.4	−10.0^d (−18.1 to −1.0)	−4.4 (−13.2 to 5.3)
West Virginia	3	12.3	8	1.0	5	20.5	46	6.2	19.8 (−17.2 to 73.4)	34.0^d (19.6 to 50.0)
Wisconsin	20	13.6	20	0.9	22	14.5	20	0.8	3.9 (−10.1 to 20.2)	4.5 (−10.6 to 22.2)
Wyoming	0	0	1	0.4	0	0	1	0.4	—ⁱ	−0.2 (−48.6 to 93.6)
Total	3772	24.0	2591	2.5	3131	19.3	2623	2.5	−5.3^d (−6.4 to −4.2)	−0.2 (−1.5 to 1.1)

Abbreviation: EAPC, estimated annual percentage change.

Data were limited to jurisdictions with complete laboratory reporting as of December 2022. Black refers to non-Hispanic Black/African American, and non-Black includes all other races and ethnicities (combined as 1 group). Data were based on residence at diagnosis. Data source: Centers for Disease Control and Prevention (CDC).¹⁴

Per 100 000 population; not calculated by transmission category because of lack of denominator data.

EAPCs indicate the per-year change, on average, based on annual rates for age group and jurisdiction of residence, and number of diagnoses for transmission category. Due to the impact of the COVID-19 pandemic on 2020 data, EAPCs were based on 4 years of data with a linear estimation of 2020 data. For simplicity, the table shows 2017 and 2021 data with 2017-2021 EAPC. Data for all years can be made available upon request.

Significant change in EAPC; 95% CIs not including 0 indicate significant trends, whereas 95% CIs including 0 indicate no significant trend.

Classified based on a hierarchy of the risk factors most likely responsible for HIV transmission, determined based on the person’s sex. Data were statistically adjusted to account for missing data for transmission category; therefore, values may not sum to column subtotals and total.

Includes people who injected nonprescription drugs or who injected prescription drugs for nonmedical purposes. Also included people with prescribed injection of drugs if there was evidence that injection equipment was shared (eg, syringes, needles, cookers).

Indicates sexual contact with a person known to have, or with a risk factor for, HIV infection.

Includes hemophilia, blood transfusion, and risk factor not reported or not identified.

Data not available for characteristics and jurisdictions with numerically unstable estimates (<12 people per year in 4 of 5 years during 2017-2021).

Data suppressed and not available for New Hampshire. Levels of suppression are in accordance with stratification levels approved by each jurisdiction under a data re-release agreement with CDC.

By region of residence, the Northeast, Midwest, and South had significant declines in HIV diagnosis rates among Black females per year (Table 1). Among non-Black females, the Northeast region had significant decreases in the rate of HIV diagnoses per year. By jurisdiction of residence, 12 of 41 jurisdictions (Delaware, District of Columbia, Florida, Georgia, Illinois, Louisiana, Maryland, Michigan, Minnesota, New York, Texas, and Washington) had significant decreases in the rates of HIV diagnoses among Black females per year. Rates remained stable in the remaining 29 jurisdictions. Among non-Black females, 3 of 41 jurisdictions (Florida, Massachusetts, and New York) had significant decreases, and 2 jurisdictions (Missouri and West Virginia) had significant increases in the rates of HIV diagnosis per year. Rates remained stable in the remaining 36 jurisdictions. Due to small case counts, we did not calculate EAPCs for Hawaii and Wyoming.

Linkage to HIV Medical Care

From 2017 through 2021, 80% (13 214 of 16 514) of Black females and 79% (10 113 of 12 711) of non-Black females who received an HIV diagnosis were linked to medical care within 1 month of diagnosis. The overall percentage of Black females linked to HIV medical care within 1 month of diagnosis increased 1.5% per year (95% CI, 0.9-2.0), and the percentage of non-Black females linked to HIV medical care within 1 month of diagnosis increased 0.8% per year (95% CI, 0.1-1.4), on average (Figure 2). By age group, we observed significant increases in linkage to HIV medical care among all age groups except for Black females aged ≥55 years and among non-Black females aged 13 to 24 years (Table 2). Among females with HIV infection attributed to heterosexual contact, the percentage of Black females linked to HIV medical care increased 1.5% (95% CI, 0.9-2.2) and the percentage of non-Black females linked to HIV medical care increased 0.9% (95% CI, 0.1-1.6) per year, on average. Trends for other age groups and transmission categories remained stable. By region of residence, the South had significant increases in the percentages of Black females linked to care, per year. By jurisdiction of residence, 5 of 41 jurisdictions (California, Florida, Georgia, North Carolina, and Texas) had significant increases in linkage to HIV medical care among Black females, and 2 of 41 jurisdictions (California and Maryland) had increases in linkage to HIV medical care among non-Black females per year. Percentages remained stable in 31 of the remaining jurisdictions. Due to small case counts, we did not calculate EAPCs for Hawaii, Montana, and Wyoming.

Figure 2.

Trends in the percentage of females linked to HIV medical care within 1 month of diagnosis and the percentage of females who achieved viral suppression within 6 months of HIV diagnosis among non-Hispanic Black/African American (indicated as Black) females and females of all other races and ethnicities (indicated as non-Black), 2017-2021 (excluding 2020), in 41 US jurisdictions. Linkage to HIV medical care was measured by documentation of ≥1 CD4+ T-lymphocyte count or viral load test within ≤1 month of HIV diagnosis during the specified year. A viral load test result of <200 copies/mL indicated HIV viral suppression and was performed within 6 months of HIV diagnosis during the specified year. The 41 jurisdictions included Alabama, Alaska, California, Colorado, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, Wyoming, and the District of Columbia. The estimated annual percentage change (EAPC) indicates the per-year percentage change, on average, in the percentage of females linked to HIV medical care within 1 month of diagnosis and the percentage of females who achieved HIV viral suppression within 6 months of diagnosis. The 95% CIs for EAPC not including 0 indicated significant trends, whereas 95% CIs for EAPCs including 0 indicated no significant trend. Data source: Centers for Disease Control and Prevention.¹⁴

Table 2.

Linkage to HIV medical care within 1 month of HIV diagnosis during 2017-2021 among females aged ≥13 years, by selected characteristics, in 41 US jurisdictions^a

Characteristic	2017				2021				2017-2021 (excluding 2020)
	Black		Non-Black		Black		Non-Black		Black, EAPC^c (95% CI)	Non-Black, EAPC^c (95% CI)
	Total diagnoses, no.	Linkage to care,^b no. (%)	Total diagnoses, no.	Linkage to care,^b no. (%)	Total diagnoses, no.	Linkage to care,^b no. (%)	Total diagnoses, no.	Linkage to care,^b no. (%)	Black, EAPC^c (95% CI)	Non-Black, EAPC^c (95% CI)
Age at diagnosis, y
13-24	549	416 (75.8)	364	274 (75.3)	432	348 (80.6)	305	251 (82.3)	1.7^d (0.1 to 3.3)	2.3^d (0.4 to 4.2)
25-34	1017	802 (78.9)	746	562 (75.3)	834	693 (83.1)	746	598 (80.2)	1.4^d (0.3 to 2.6)	1.1 (−0.1 to 2.4)
35-44	838	646 (77.1)	606	461 (76.1)	776	642 (82.7)	712	571 (80.2)	1.5^d (0.4 to 2.6)	1.0 (−0.2 to 2.3)
45-54	724	566 (78.2)	504	417 (82.7)	566	470 (83.0)	493	397 (80.5)	1.6^d (0.3 to 2.9)	−0.5 (−2.0 to 1.1)
≥55	644	508 (78.9	371	306 (82.5)	523	435 (83.2)	367	298 (81.2)	1.1 (−0.2 to 2.3)	−0.2 (−1.8 to 1.4)
Transmission category^e
Injection drug use^f	310	242 (78.0)	622	468 (75.3)	261	211 (80.9)	663	509 (76.8)	1.0 (−2.6 to 4.7)	0.4 (−1.2 to 2.1)
Heterosexual contact^g	3436	2674 (77.8)	1958	1542 (78.8)	2843	2355 (82.8)	1945	1593 (81.9)	1.5^d (0.9 to 2.2)	0.9^d (0.1 to 1.6)
Other^h	26	23 (86.9)	12	10 (85.2)	27	22 (80.4)	15	13 (85.6)	−0.8 (−7.2 to 6.0)	2.2 (−10.4 to 16.7)
Region of residence
Northeast	384	318 (82.8)	353	295 (83.6)	286	251 (87.8)	261	226 (86.6)	1.4 (−0.1 to 2.9)	1.0 (−0.6 to 2.6)
Midwest	557	477 (85.6)	360	284 (78.9)	462	389 (84.2)	407	322 (79.1)	0.1 (−1.3 to 1.6)	0.1 (−1.6 to 1.8)
South	2617	1982 (75.7)	1331	1016 (76.3)	2189	1788 (81.7)	1380	1094 (79.3)	1.7^d (1.0 to 2.4)	0.8 (−0.2 to 1.7)
West	214	161 (75.2)	547	425 (77.7)	194	160 (82.5)	575	473 (82.3)	1.6 (−0.4 to 3.7)	1.4^d (0 to 2.8)
Jurisdiction of residence
Alabama	99	83 (83.8)	36	27 (75.0)	85	73 (85.9)	44	37 (84.1)	0.2 (−2.8 to 3.2)	4.7 (−1.0 to 10.7)
Alaska	1	1 (100.0)	7	7 (100.0)	1	1 (100.0)	4	4 (100.0)	0 (−55.1 to 122.6)	−1.2 (−27.5 to 34.7)
California	142	98 (69.0)	402	297 (73.9)	129	104 (80.6)	425	350 (82.4)	3.6^d (0.7 to 6.5)	2.7^d (1.0 to 4.4)
Colorado	15	11 (73.3)	26	22 (84.6)	14	11 (78.6)	39	31 (79.5)	−0.6 (−18.4 to 21.0)	−2.1 (−6.9 to 2.9)
Delaware	25	23 (92.0)	10	10 (100.0)	11	11 (100.0)	7	4 (57.1)	5.0 (−8.7 to 20.8)	−17.9 (−40.1 to 12.6)
District of Columbia	67	51 (76.1)	8	7 (87.5)	42	33 (78.6)	4	4 (100.0)	0.3 (−4.5 to 5.4)	3.2 (−22.8 to 38.1)
Florida	611	459 (75.1)	374	286 (76.5)	499	403 (80.8)	328	248 (75.6)	1.7^d (0.2 to 3.1)	−0.6 (−2.5 to 1.2)
Georgia	445	333 (74.8)	115	81 (70.4)	367	298 (81.2)	101	80 (79.2)	2.1^d (0.3 to 4.0)	2.9 (−0.5 to 6.3)
Hawaii	0	0	6	5 (83.3)	2	2 (100.0)	9	8 (88.9)	—ⁱ	0 (−13.3 to 15.3)
Illinois	160	134 (83.8)	63	51 (81.0)	111	91 (82.0)	76	64 (84.2)	0.1 (−3.4 to 3.7)	2.3 (−1.6 to 6.3)
Indiana	52	46 (88.5)	55	38 (69.1)	60	49 (81.7)	47	38 (80.9)	−1.0 (−6.7 to 5.1)	3.9 (−1.3 to 9.5)
Iowa	13	12 (92.3)	11	10 (90.9)	9	6 (66.7)	17	16 (94.1)	−6.6 (−16.3 to 4.3)	0.3 (−5.0 to 6.0)
Louisiana	186	154 (82.8)	50	37 (74.0)	147	114 (77.6)	61	53 (86.9)	−1.7 (−4.3 to 1.0)	3.2 (−0.6 to 7.2)
Maine	1	1 (100.0)	3	3 (100.0)	3	3 (100.0)	1	1 (100.0)	0 (−38.6 to 63.0)	0 (−39.9 to 66.3)
Maryland	223	191 (85.7)	59	44 (74.6)	143	130 (90.9)	39	36 (92.3)	1.6 (−0.5 to 3.8)	5.4^d (1.4 to 9.6)
Massachusetts	64	61 (95.3)	87	76 (87.4)	74	67 (90.5)	59	56 (94.9)	−0.3 (−2.9 to 2.3)	2.6 (−0.1 to 5.4)
Michigan	96	78 (81.3)	45	38 (84.4)	61	54 (88.5)	38	31 (81.6)	2.6 (−0.4 to 5.7)	−0.6 (−5.5 to 4.5)
Minnesota	51	47 (92.2)	21	17 (81.0)	35	31 (88.6)	29	24 (82.8)	−0.3 (−3.5 to 2.9)	0.4 (−4.1 to 5.1)
Mississippi	89	61 (68.5)	19	12 (63.2)	82	59 (72.0)	31	17 (54.8)	5.4^d (1.4 to 5.0)	−4.4 (−11.8 to 3.6)
Missouri	69	57 (82.6)	32	21 (65.6)	50	41 (82.0)	53	39 (73.6)	0.3 (−4.1 to 5.0)	1.4 (−4.4 to 7.7)
Montana	0	0	2	2 (100.0)	0	0	2	2 (100.0)	—ⁱ	0 (−37.3 to 59.6)
Nebraska	6	5 (83.3)	9	6 (66.7)	5	4 (80.0)	13	10 (76.9)	−1.1 (−10.7 to 9.6)	2.6 (−9.1 to 15.7)
New Hampshire^j	—	—	—	—	—	—	—	—	—	—
New Mexico	2	2 (100.0)	17	17 (100.0)	2	0	18	14 (77.8)	−34.1 (−67.0 to 31.7)	−6.9 (−15.5 to 2.6)
New York	311	249 (80.1)	247	202 (81.8)	206	178 (86.4)	188	159 (84.6)	1.7 (−0.2 to 3.6)	1.0 (−1.1 to 3.0)
North Carolina	177	136 (76.8)	75	63 (84.0)	165	143 (86.7)	83	71 (85.5)	2.7^d (0.5 to 4.9)	1.4 (−2.7 to 5.7)
North Dakota	6	5 (83.3)	1	1 (100.0)	8	7 (87.5)	6	4 (66.7)	0.5 (−5.9 to 7.3)	−11.9 (−41.1 to 31.8)
Ohio	81	73 (90.1)	97	79 (81.4)	100	87 (87.0)	103	78 (75.7)	−0.9 (−3.8 to 2.0)	−2.0 (−5.5 to 1.6)
Oklahoma	25	16 (64.0)	26	16 (61.5)	25	21 (84.0)	44	33 (75.0)	6.8 (−1.4 to 15.7)	2.5 (−3.5 to 9.0)
Oregon	7	4 (57.1)	30	25 (83.3)	5	5 (100.0)	24	16 (66.7)	12.9 (−17.1 to 53.7)	−4.6 (−17.5 to 10.5)
Rhode Island	8	7 (87.5)	8	8 (100.0)	3	3 (100.0)	8	5 (62.5)	−1.0 (−16.4 to 17.2)	−10.7 (−31.2 to 15.9)
South Carolina	93	76 (81.7)	66	57 (86.4)	78	66 (84.6)	64	56 (87.5)	0.8 (−2.2 to 3.9)	0.1 (−2.8 to 3.1)
South Dakota	3	3 (100.0)	6	5 (83.3)	1	1 (100.0)	5	4 (80.0)	0 (−42.1 to 72.8)	−4.0 (−19.4 to 14.4)
Tennessee	71	42 (59.2)	55	33 (60.0)	92	66 (71.7)	69	51 (73.9)	2.9 (−1.5 to 7.4)	3.9 (−1.5 to 9.6)
Texas	387	272 (70.3)	362	283 (78.2)	349	286 (81.9)	401	327 (81.5)	3.8^d (1.8 to 5.9)	1.0 (−0.8 to 2.7)
Utah	5	4 (80.0)	6	5 (83.3)	2	2 (100.0)	8	7 (87.5)	6.0 (−40.2 to 87.8)	1.1 (−10.5 to 14.2)
Virginia	116	84 (72.4)	68	55 (80.9)	99	81 (81.8)	58	46 (79.3)	2.6 (−0.3 to 5.7)	0.8 (−3.8 to 5.7)
Washington	42	41 (97.6)	50	45 (90.0)	39	35 (89.7)	45	40 (88.9)	−1.5 (−3.4 to 0.4)	−0.1 (−3.5 to 3.6)
West Virginia	3	1 (33.3)	8	5 (62.5)	5	4 (80.0)	46	31 (67.4)	18.3 (−13.8 to 62.4)	−2.4 (−10.7 to 6.6)
Wisconsin	20	17 (85.0)	20	18 (90.0)	22	18 (81.8)	20	14 (70.0)	−0.4 (−6.0 to 5.4)	−6.0 (−12.5 to 0.9)
Wyoming	0	0	1	0	0	0	1	1 (100.0)	—ⁱ	28.9 (−38.6 to 170.9)
Total	3772	2938 (77.9)	2591	2020 (78.0)	3131	2588 (82.7)	2623	2115 (80.6)	1.5^d (0.9 to 2.0)	0.8^d (0.1 to 1.4)

Abbreviations: CD4, CD4 + T-lymphocyte count (cells/μL) or percentage; EAPC, estimated annual percentage change; VL, viral load (copies/mL).

Data were limited to jurisdictions that had complete laboratory reporting as of December 2022. Black refers to non-Hispanic Black/African American, and non-Black includes all other races and ethnicities (combined as 1 group). Data were based on residence at diagnosis. Data source: Centers for Disease Control and Prevention (CDC).¹⁴

Measured by documentation of ≥1 CD4 or VL test ≤1 month after HIV diagnosis.

EAPCs indicate the per-year change, on average, in the percentage linked to HIV medical care. Due to the impact of the COVID-19 pandemic on 2020 data, EAPCs were based on 4 years of data with a linear estimation of 2020 data. For simplicity, the table shows 2017 and 2021 data with 2017-2021 EAPCs. Data for all years can be made available upon request.

Significant change in EAPC; 95% CIs not including 0 indicate significant trends, whereas 95% CIs including 0 indicate no significant trend.

Classified based on a hierarchy of the risk factors most likely responsible for HIV transmission; determined based on the person’s sex. Data were statistically adjusted to account for missing data for transmission category; therefore, values may not sum to column subtotals and total.

Indicates sexual contact with a person known to have, or with a risk factor for, HIV infection.

Includes hemophilia, blood transfusion, and risk factors not reported or not identified.

Data not available for characteristics and jurisdictions with numerically unstable estimates (<12 people per year in 4 of 5 years during 2017-2021).

Data suppressed and not available for New Hampshire. Levels of suppression are in accordance with stratification levels approved by each jurisdiction under a data re-release agreement with CDC.

Viral Suppression

From 2017 to 2021, 70% (11 184 of 16 514) of Black females and 66% (8272 of 12 711) of non-Black females had viral suppression within 6 months of HIV diagnosis. The overall percentage of Black females with viral suppression within 6 months of diagnosis increased 1.6% per year (95% CI, 0.8-2.4), and the percentage of non-Black females with viral suppression within 6 months of diagnosis increased 1.4% (95% CI, 0.5-2.4) per year, on average. By age group, significant increases in viral suppression were observed among Black females aged 45 to 54 years and among non-Black females aged 13 to 24 and 25 to 34 years. Among females with HIV infection attributed to heterosexual contact, the percentage of Black females with viral suppression increased 1.5% (95% CI, 0.7-2.3) and the percentage of non-Black females with viral suppression increased 1.7% (95% CI, 0.7-2.7) per year, on average. Trends for other age groups and transmission categories remained stable. By region of residence, the Midwest and South had significant increases in viral suppression among both Black and non-Black females (Table 3). The Northeast had significant increases in viral suppression among Black females per year. By jurisdiction of residence, 4 of 41 jurisdictions (Georgia, New York, Ohio, and Wisconsin) had significant increases in viral suppression among Black females, and 4 of 41 jurisdictions (Illinois, Maryland, North Carolina, and Texas) had significant increases in viral suppression among non-Black females per year. Percentages remained stable per year in 31 of the remaining jurisdictions. Due to small case counts, we did not calculate EAPCs for Hawaii, Montana, and Wyoming.

Table 3.

Viral suppression within 6 months of HIV diagnosis among females aged ≥13 years with HIV diagnosed during 2017-2021, by selected characteristics, in 41 US jurisdictions^a

Characteristic	2017				2021				2017-2021 (excluding 2020)
	Black		Non-Black		Black		Non-Black		Black, EAPC^c (95% CI)	Non-Black, EAPC^c (95% CI)
	Total diagnoses, no.	VL < 200 copies/mL,^b no. (%)	Total diagnoses, no.	VL < 200 copies/mL,^b no. (%)	Total diagnoses, no.	VL < 200 copies/mL,^b no. (%)	Total diagnoses, no.	VL < 200 copies/mL,^b no. (%)	Black, EAPC^c (95% CI)	Non-Black, EAPC^c (95% CI)
Age at diagnosis, y
13-24	549	362 (65.9)	364	212 (58.2)	432	301 (69.7)	305	212 (69.5)	1.7 (−0.4 to 3.9)	3.4^d (0.9 to 6.0)
25-34	1017	683 (67.2)	746	450 (60.3)	834	583 (69.9)	746	498 (66.8)	1.4 (−0.1 to 3.0)	1.9^d (0.2 to 3.6)
35-44	838	543 (64.8)	606	372 (61.4)	776	536 (69.1)	712	470 (66.0)	1.1 (−0.4 to 2.7)	1.5 (−0.4 to 3.5)
45-54	724	463 (64.0)	504	337 (66.9)	566	417 (73.7)	493	315 (63.9)	3.2^d (1.5 to 5.0)	−1.1 (−3.4 to 1.1)
≥55	644	410 (63.7)	371	241 (65.0)	523	345 (66.0)	367	250 (68.1)	0.6 (−1.3 to 2.5)	1.9 (−0.6 to 4.4)
Transmission category^e
Injection drug use^f	310	171 (55.3)	622	299 (48.0)	261	161 (61.7)	663	335 (50.6)	2.8 (−1.7 to 7.5)	0.6 (−2.2 to 3.6)
Heterosexual contact^g	3436	2274 (66.2)	1958	1307 (66.7)	2843	2002 (70.4)	1945	1398 (71.9)	1.5^d (0.7 to 2.3)	1.7^d (0.7 to 2.7)
Other^h	26	16 (61.4)	12	7 (58.3)	27	19 (68.9)	15	12 (77.8)	3.2 (−7.2 to 14.6)	6.7 (−11.4 to 28.6)
Region of residence
Northeast	384	280 (72.9)	353	257 (72.8)	286	230 (80.4)	261	199 (76.2)	2.2^d (0.3 to 4.3)	1.4 (−0.8 to 3.7)
Midwest	557	363 (65.2)	360	219 (60.8)	462	333 (72.1)	407	280 (68.8)	2.2^d (0.2 to 4.2)	3.0^d (0.6 to 5.5)
South	2617	1679 (64.2)	1331	798 (60.0)	2189	1477 (67.5)	1380	891 (64.6)	1.4^d (0.4 to 2.3)	1.6^d (0.2 to 2.9)
West	214	139 (65.0)	547	338 (61.8)	194	142 (73.2)	575	375 (65.2)	2.2 (−0.6 to 5.2)	0.7 (−1.3 to 2.8)
Jurisdiction of residence
Alabama	99	70 (70.7)	36	20 (55.6)	85	58 (68.2)	44	28 (63.6)	−0.7 (−5.3 to 4.1)	3.0 (−4.5 to 11.2)
Alaska	1	0	7	3 (42.9)	1	1 (100.0)	4	4 (100.0)	55.7 (−82.2 to 1258.3)	18.0 (−21.1 to 76.5)
California	142	87 (61.3)	402	232 (57.7)	129	87 (67.4)	425	264 (62.1)	2.5 (−1.7 to 6.9)	0.9 (−1.6 to 3.5)
Colorado	15	12 (80.0)	26	23 (88.5)	14	11 (78.6)	39	34 (87.2)	−0.4 (−8.2 to 8.0)	2.1 (−4.5 to 9.2)
Delaware	25	22 (88.0)	10	7 (70.0)	11	8 (72.7)	7	6 (85.7)	−3.2 (−12.1 to 6.6)	5.3 (−15.0 to 30.4)
District of Columbia	67	38 (56.7)	8	3 (37.5)	42	27 (64.3)	4	4 (100.0)	4.0 (−3.2 to 11.7)	35.1 (−28.4 to 155.2)
Florida	611	377 (61.7)	374	238 (63.6)	499	327 (65.5)	328	202 (61.6)	1.4 (−0.7 to 3.5)	−0.6 (−3.2 to 2.0)
Georgia	445	273 (61.3)	115	62 (53.9)	367	245 (66.8)	101	62 (61.4)	2.9^d (0.3 to 5.5)	2.9 (−2.1 to 8.0)
Hawaii	0	0	6	5 (83.3)	2	2 (100.0)	9	6 (66.7)	—ⁱ	−4.8 (−19.7 to 12.9)
Illinois	160	84 (52.5)	63	35 (55.6)	111	67 (60.4)	76	58 (76.3)	2.5 (−2.1 to 7.4)	7.0^d (1.8 to 12.4)
Indiana	52	36 (69.2)	55	29 (52.7)	60	47 (78.3)	47	31 (66.0)	4.6 (−1.8 to 11.5)	5.9 (−1.6 to 14.0)
Iowa	13	10 (76.9)	11	10 (90.9)	9	6 (66.7)	17	14 (82.4)	−4.4 (−14.4 to 6.6)	−3.7 (−11.5 to 4.9)
Louisiana	186	131 (70.4)	50	39 (78.0)	147	108 (73.5)	61	42 (68.9)	1.3 (−2.0 to 4.7)	−3.2 (−8.5 to 2.4)
Maine	1	1 (100.0)	3	2 (66.7)	3	2 (66.7)	1	1 (100.0)	−9.7 (−42.5 to 41.8)	9.4 (−24.4 to 58.2)
Maryland	223	151 (67.7)	59	26 (44.1)	143	103 (72.0)	39	30 (76.9)	0.9 (−1.9 to 3.9)	10.9^d (3.7 to 18.5)
Massachusetts	64	55 (85.9)	87	59 (67.8)	74	62 (83.8)	59	45 (76.3)	0.1 (−3.6 to 3.9)	3.7 (−1.0 to 8.7)
Michigan	96	72 (75.0)	45	31 (68.9)	61	47 (77.0)	38	24 (63.2)	1.2 (−2.9 to 5.5)	−1.5 (−8.0 to 5.4)
Minnesota	51	42 (82.4)	21	18 (85.7)	35	27 (77.1)	29	21 (72.4)	−3.1 (−8.9 to 3.1)	−2.4 (−10.1 to 6.1)
Mississippi	89	56 (62.9)	19	10 (52.6)	82	53 (64.6)	31	16 (51.6)	2.4 (−3.6 to 8.8)	0.8 (−10.4 to 13.5)
Missouri	69	46 (66.7)	32	23 (71.9)	50	38 (76.0)	53	38 (71.7)	2.7 (−2.9 to 8.5)	2.3 (−4.7 to 9.9)
Montana	0	0	2	2 (100.0)	0	0	2	2 (100.0)	—ⁱ	−1.3 (−39.8 to 61.8)
Nebraska	6	5 (83.3)	9	5 (55.6)	5	1 (20.0)	13	9 (69.2)	−26.7^d (−44.2 to −3.5)	3.4 (−10.9 to 20.1)
New Hampshire^j	—	—	—	—	—	—	—	—	—	—
New Mexico	2	1 (50.0)	17	15 (88.2)	2	0	18	11 (61.1)	−26.7 (−59.9 to 34.0)	−10.0 (−22.3 to 4.3)
New York	311	216 (69.5)	247	181 (73.3)	206	163 (79.1)	188	144 (76.6)	2.9^d (0.5 to 5.3)	1.2 (−1.4 to 3.8)
North Carolina	177	127 (71.8)	75	49 (65.3)	165	125 (75.8)	83	65 (78.3)	1.4 (−1.6 to 4.4)	5.9^d (0.7 to 11.4)
North Dakota	6	5 (83.3)	1	1 (100.0)	8	4 (50.0)	6	5 (83.3)	−9.3 (−21.2 to 4.5)	2.8 (−16.8 to 27.2)
Ohio	81	46 (56.8)	97	49 (50.5)	100	74 (74.0)	103	65 (63.1)	5.3^d (0.9 to 9.9)	5.1 (−0.7 to 11.2)
Oklahoma	25	14 (56.0)	26	11 (42.3)	25	17 (68.0)	44	25 (56.8)	6.2 (−4.3 to 17.8)	5.7 (−4.5 to 16.9)
Oregon	7	3 (42.9)	30	17 (56.7)	5	4 (80.0)	24	14 (58.3)	10.7 (−6.8 to 31.3)	0.1 (−8.0 to 9.0)
Rhode Island	8	8 (100.0)	8	8 (100.0)	3	3 (100.0)	8	5 (62.5)	−10.8 (−39.5 to 31.5)	−11.5 (−32.2 to 15.6)
South Carolina	93	61 (65.6)	66	46 (69.7)	78	59 (75.6)	64	51 (79.7)	3.0 (−1.2 to 7.4)	2.4 (−2.2 to 7.2)
South Dakota	3	3 (100.0)	6	4 (66.7)	1	1 (100.0)	5	3 (60.0)	0 (−42.1 to 72.8)	−6.2 (−30.5 to 26.5)
Tennessee	71	43 (60.6)	55	29 (52.7)	92	58 (63.0)	69	45 (65.2)	1.2 (−4.1 to 6.8)	6.2 (−0.6 to 13.4)
Texas	387	241 (62.3)	362	215 (59.4)	349	217 (62.2)	401	268 (66.8)	0 (−2.7 to 2.8)	2.9^d (0.2 to 5.5)
Utah	5	1 (20.0)	6	5 (83.3)	2	2 (100.0)	8	4 (50.0)	37.0 (−12.4 to 114.3)	−12.4 (−25.5 to 3.1)
Virginia	116	74 (63.8)	68	39 (57.4)	99	72 (72.7)	58	36 (62.1)	2.5 (−1.2 to 6.3)	0.5 (−5.0 to 6.3)
Washington	42	35 (83.3)	50	36 (72.0)	39	35 (89.7)	45	36 (80.0)	1.0 (−2.4 to 4.6)	2.3 (−3.3 to 8.3)
West Virginia	3	1 (33.3)	8	4 (50.0)	5	0	46	11 (23.9)	−54.4 (−87.5 to 66.8)	−19.3^d (−30.6 to −6.2)
Wisconsin	20	14 (70.0)	20	14 (70.0)	22	21 (95.5)	20	12 (60.0)	6.6^d (1.3 to 12.3)	−4.1 (−12.3 to 4.9)
Wyoming	0	0	1	0	0	0	1	0	—ⁱ	−34.1 (−87.6 to 251.1)
Total	3772	2461 (65.2)	2591	1612 (62.2)	3131	2182 (69.7)	2623	1745 (66.5)	1.6^d (0.8 to 2.4)	1.4^d (0.5 to 2.4)

Abbreviations: EAPC, estimated annual percentage change; VL, viral load (copies/mL).

A VL test result of <200 copies/mL indicates HIV viral suppression. VL test results were within 6 months of diagnosis of HIV infection during the specified year.

EAPC results indicate the per-year change, on average, in the percentage who were virally suppressed. Due to the impact of the COVID-19 pandemic on 2020 data, EAPCs were based on 4 years of data with a linear estimation of 2020 data. For simplicity, the table shows 2017 and 2021 data with 2017-2021 EAPCs. Data for all years can be made available upon request.

Significant change in EAPC; 95% CIs not including 0 indicate significant trends, whereas 95% CIs including 0 indicate no significant trend.

Includes people who injected nonprescription drugs or who injected prescription drugs for nonmedical purposes. Also includes people with prescribed injection of drugs if there was evidence that injection equipment was shared (eg, syringes, needles, cookers).

Indicates sexual contact with a person known to have, or with a risk factor for, HIV infection.

Includes hemophilia, blood transfusion, and risk factor not reported or not identified.

Data not available for selected characteristics and jurisdictions with numerically unstable estimates (<12 people per year in 4 of 5 years during 2017-2021).

Data suppressed and not available for New Hampshire. Levels of suppression are in accordance with stratification levels approved by each jurisdiction under a data re-release agreement with CDC.

Discussion

Our study assessed trends in HIV diagnoses and HIV care outcomes among Black and non-Black females from 2017 through 2021. Overall, we found progress, with declines in annual rates of HIV diagnosis among Black females. Annual HIV rates for non-Black females remained stable. Limited progress in linkage to care and early viral suppression occurred among Black and non-Black females. Trends varied by age, transmission category, and area of residence.

Our results showed significant declines in HIV diagnoses among Black females across all age groups and in several jurisdictions. One study suggested that observed declines in the diagnosis rates of sexually transmitted infections and HIV among potential male partners and increased percentages of viral suppression among heterosexual and bisexual HIV-positive potential male partners might be contributing factors to declines in HIV diagnoses among Black females.¹⁸ These declines may also be attributed to national initiatives aimed at decreasing HIV infections across priority populations.^13,19,20 The Ending the HIV Epidemic: A Plan for America (EHE) initiative, for example, has aimed to reduce new HIV infections by 75% by 2025 and by at least 90% by 2030.²⁰ Efforts of the EHE initiative have led to increases in HIV testing, implementation of rapid linkage-to-care programs, and expanded access to targeted prevention services in priority jurisdictions.²¹ This progress is promising as the gap in diagnoses between racial and ethnic groups has narrowed. To reach the goals of the EHE initiative, more efforts are needed, such as the inclusion of females in clinical trials to enhance the availability of various biomedical prevention treatment options, improvements in health care access and essential support services, and efforts to address the social and structural disadvantages that perpetuate health inequities.²²

Among the US jurisdictions with complete laboratory reporting to CDC, we found significant declines in annual rates of HIV diagnoses among Black females in 16 states designated EHE priority areas. The jurisdictions with the greatest declines in HIV diagnoses among Black and non-Black females have strong HIV programs already in place.^22-26 Increases in HIV diagnoses among non-Black females were reported in Missouri and West Virginia. Increases in West Virginia counties have previously been linked to injection drug use among people who inject drugs.²⁷ These increases may also result from ongoing care and prevention challenges experienced in rural areas. For example, high concentrations of HIV infection were reported in rural areas of Missouri from 2014 to 2018. Missouri was the state with the least progress in HIV outcomes among all groups.²⁸ Rural communities are more likely than urban communities to lack vital services and support for prevention strategies such as preexposure prophylaxis and routine HIV testing,^4,28 which can contribute to accelerated HIV transmission associated with opioid misuse in these areas.^29-32 Among the several existing platforms that promote the importance of HIV prevention and care among females are organizations such as Sister Love (https://www.sisterlove.org) and Own Our Own Terms (https://ooot.bwhi.org), which combine evidence-based practices and cross-sector collaborations to address HIV prevention needs while supporting ongoing efforts tailored for females from marginalized communities.

Linkage to HIV medical care among females mirrors the 2021 national data of 82% of people with HIV linked to care within 1 month of diagnosis.⁷ Although more work is needed to improve linkage to care, the percentage of Black females linked to care was higher in 2021 than in 2017. Strategies to increase linkage to care among females must include increasing community awareness of HIV, meeting them where they are, including HIV testing and care in routine health screenings, and developing policies that address social and structural determinants of health.

Rapid linkage to care and antiretroviral therapy is an effective strategy following HIV diagnosis to accelerate entry into HIV medical care and can help reduce time to viral suppression.^33,34 In jurisdictions where rapid entry programs exist, patient navigation services are vital. Patient navigation is a patient-centered care coordination model, often used with economically disadvantaged populations to address health disparities and poor health outcomes, focused on reducing barriers to care.^35,36 Patient navigation services may be a beneficial avenue for assisting Black females with linkage to HIV medical care and other support services, including housing and employment.^35,36 Receipt of essential support services can improve retention in care, which may lead to viral suppression. However, dedicated efforts with patient navigation to improve access and use could contribute to improved overall health outcomes.

Viral suppression, one of the 6 EHE indicators, is a key measure for monitoring adherence to antiretroviral therapy and assessing quality of care among people with HIV.²⁰ In our analysis, approximately two-thirds of Black and non-Black females were virally suppressed within 6 months of diagnosis in 2021, a finding similar to national data for the overall population (68%).⁷ Factors associated with everyday life (ie, housing stability, access to transportation, poverty, employment status, and adherence to antiretroviral therapy) may hinder progress along the HIV care continuum and can impede sustained viral suppression among females living with HIV.^37-42 Stigma is another aspect of living with HIV for Black females, and the long-lasting effects of stigma on receipt of care and maintaining viral suppression have been documented.^43-45 Although the rate of linkage to HIV care at 80% for Black and non-Black females is promising, additional efforts are warranted to continue care engagement and increase early viral suppression among females to reach outcome goals.

Limitations

Our study had several limitations. First, data were available from only 41 US jurisdictions with complete reporting of HIV-related laboratory data to CDC; however, data reported from these jurisdictions accounted for 88% of people living with diagnosed HIV infections in the United States. Second, several jurisdictions in our analysis had small numbers. Data for these jurisdictions should be interpreted with caution. Third, CD4 and viral load test results during the follow-up period may be missing for people who either did not have tests taken or moved to another jurisdiction after HIV diagnosis, leading to delayed reporting to CDC. Fourth, CD4 and viral load tests are HIV care proxies used to monitor health outcomes, and not having these tests reported or performed limited the assessment of care. As a result, some females who were engaged in care may have been misclassified as not linked to HIV medical care or not being virally suppressed. Finally, the COVID-19 pandemic during 2020 in the United States led to disruptions in clinical care services, which significantly impacted HIV diagnoses and reporting likely due to patient hesitancy in accessing services and shortages in HIV testing materials.¹ Assessment of trends in HIV diagnoses that include data from 2020 should be interpreted with caution; thus, our analysis excluded 2020 data to align with CDC guidelines.⁴⁶ During 2021, HIV diagnoses partially rebounded (by 18% compared with 2020), which may be due to delayed diagnoses and reporting from 2020.¹

Conclusions

Our results underscore the importance of routine HIV screening and rapid linkage to HIV medical care and early viral suppression for females, particularly Black females, who are disproportionately affected by HIV. Our results also highlight gaps in service delivery along the HIV care continuum for females by race, age, and jurisdiction of residence. Efforts are needed to ensure equitable access to HIV testing, treatment, and prevention services, particularly for females disproportionately affected by HIV.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Ndidi Nwangwu-Ike, MPH

Shacara Johnson Lyons, MSPH

Disclaimers

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

References

Centers for Disease Control and Prevention. Diagnoses of HIV infection in the United States and dependent areas, 2021. HIV Surveill Rep. 2023;34:1-82. Accessed April 13, 2024. https://stacks.cdc.gov/view/cdc/149071

May

Murray

Sutton

MY.

HIV infection among women in the United States: 2000-2017. AIDS Care. 2019;32(4):522-529. doi:10.1080/09540121.2019.1640844

Bradley

Williams

Green

, et al. Disparities in incidence of human immunodeficiency virus infection among Black and White women—United States, 2010-2016. MMWR Morb Mortal Wkly Rep. 2019;68(18):416-418. doi:10.15585/mmwr.mm6818a3

Sullivan

Satcher Johnson

Pembleton

, et al. Epidemiology of HIV in the USA: epidemic burden, inequities, contexts, and responses. Lancet. 2021;397(10279):1095-1106. doi:10.1016/S0140-6736(21)00395-0

Marmot

Friel

Bell

Houweling

Taylor

; Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet. 2008;372(9650):1661-1669. doi:10.1016/S0140-6736(08)61690-6

Menza

Hixson

Lipira

Drach

Social determinants of health and care outcomes among people with HIV in the United States. Open Forum Infect Dis. 2021;8(7):ofab330. doi:10.1093/ofid/ofab330

Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2021. HIV Surveill Suppl Rep. 2023;28(4):1-167. Accessed April 13, 2024. https://stacks.cdc.gov/view/cdc/160195

Geter

Sutton

Armon

Buchacz

Disparities in viral suppression and medication adherence among women in the USA, 2011-2016. AIDS Behav. 2019;23(11):3015-3023. doi:10.1007/s10461-019-02494-9

Beer

Mattson

Bradley

Skarbinski

; Medical Monitoring Project. Understanding cross-sectional racial, ethnic, and gender disparities in antiretroviral use and viral suppression among HIV patients in the United States. Medicine (Baltimore). 2016;95(13):e3171. doi:10.1097/MD.0000000000003171

10.

Borchelt

GR.

The impact poverty has on women’s health. Human Rights. 2018;43(3):16-19.

11.

Patchias

Waxman

Women and health coverage: the affordability gap. Issue Brief (Commonw Fund). 2007;25:1-12.

12.

Lee

Chien

Stewart

, et al. Women’s coverage, utilization, affordability, and health after the ACA: a review of the literature. Health Aff (Millwood). 2020;39(3):387-394. doi:10.1377/hlthaff.2019.01361

13.

The White House. National HIV/AIDS strategy for the United States 2022-2025. 2021. Accessed March 27, 2024. https://files.hiv.gov/s3fs-public/NHAS-2022-2025.pdf

14.

Centers for Disease Control and Prevention. National Center for HIV, Viral Hepatitis, STD, and TB Prevention AtlasPlus, 2010-2022. December 2024. Accessed July 8, 2025. https://gis.cdc.gov/grasp/nchhstpatlas/main.html

15.

Cohen

Gray

Ocfemia

Johnson

Hall

HI.

The status of the National HIV Surveillance System, United States, 2013. Public Health Rep. 2014;129(4):335-341. doi:10.1177/003335491412900408

16.

Office of Management and Budget. Revised delineations of metropolitan statistical areas, micropolitan statistical areas, and combined statistical areas, and guidance on uses of the delineations of these areas. OMB Bulletin 17-01. Published August 15, 2017. Accessed February 5, 2024. https://www.whitehouse.gov/wp-content/uploads/legacy_drupal_files/omb/bulletins/2017/b-17-01.pdf

17.

Harrison

Kajese

Hall

Song

Risk factor redistribution of the national HIV/AIDS surveillance data: an alternative approach. Public Health Rep. 2008;123(5):618-627. doi:10.1177/003335490812300512

18.

McCree

Jeffries WL

Beer

Gant

Elmore

Sutton

Exploring factors associated with declining HIV diagnoses among African American females. J Racial Ethn Health Disparities. 2018;5(3):598-604. doi:10.1007/s40615-017-0405-6

19.

US Department of Health and Human Services. Healthy People 2030. Objectives and measures. 2023. Accessed May 26, 2024. https://odphp.health.gov/healthypeople/objectives-and-data/about-objectives/healthy-people-2030-objectives-and-measures

20.

Fauci

Redfield

Sigounas

Weahkee

Giroir

BP.

Ending the HIV Epidemic: a plan for the United States. JAMA. 2019;321(9):844-845. doi:10.1001/jama.2019.1343

21.

Patel

Mulatu

Wang

May

Moore

Rao

CDC-funded HIV testing services outcomes in Ending the HIV Epidemic in the United States (EHE) and non-EHE jurisdictions, 2021. J Infect Dis. 2025;231(1):147-155. doi:10.1093/infdis/jiae430

22.

Adimora

Ramirez

Poteat

, et al. HIV and women in the USA: what we know and where to go from here. Lancet. 2021;397(10279):1107-1115. doi:10.1016/S0140-6736(21)00396-2

23.

Tesoriero

Johnson

Hart-Malloy

, et al. Improving retention in HIV care through New York’s expanded partner services data-to-care pilot. J Public Health Manag Pract. 2017;23(3):255-263. doi:10.1097/PHH.0000000000000483

24.

Project Inform. Using surveillance and other data to improve HIV care linkage and retention. 2012. Accessed June 18, 2024. https://www.urccp.org/Images_Content/Site1/Files/Pages/Think_Tank_Report-_Surv_Data_for_LTC.pdf

25.

Sweeney

DiNenno

Flores

, et al. HIV data to care—using public health data to improve HIV care and prevention. J Acquir Immune Defic Syndr. 2019;82(Suppl 1):S1-S5. doi:10.1097/QAI.0000000000002059

26.

Giroir

BP.

The time is now to end the HIV epidemic. Am J Public Health. 2020;110(1):22-24. doi:10.2105/AJPH.2019.305380

27.

Bradley

Hogan

Agnew-Brune

, et al. Increased HIV diagnoses in West Virginia counties highly vulnerable to rapid HIV dissemination through injection drug use: a cautionary tale. Ann Epidemiol. 2019;34:12-17. doi:10.1016/j.annepidem.2019.02.012

28.

Dailey

Johnson

Gant

Lyons

Adih

Trends in HIV care outcomes among adults and adolescents—33 jurisdictions, United States, 2014-2018. J Acquir Immun Defic Syndr. 2021;88(4):333-339. doi:10.1097/QAI.0000000000002778

29.

Conrad

Bradley

Broz

, et al. Community outbreak of HIV infection linked to injection drug use of oxymorphone—Indiana, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(16):443-444.

30.

Lerner

Fauci

AS.

Opioid injection in rural areas of the United States: a potential obstacle to ending the HIV epidemic. JAMA. 2019;322(11):1041-1042. doi:10.1001/jama.2019.10657

31.

Evans

Labuda

Hogan

, et al. Notes from the field: HIV infection investigation in a rural area—West Virginia, 2017. MMWR Morb Mortal Wkly Rep. 2018;67(8):257-258. doi:10.15585/mmwr.mm6708a6

32.

Hodder

Feinberg

Strathdee

, et al. The opioid crisis and HIV in the USA: deadly synergies. Lancet. 2021;397(10279):1139-1150. doi:10.1016/S0140-6736(21)00391-3

33.

Bourdeau

Shade

Koester

, et al. Rapid start antiretroviral therapies for improved engagement in HIV care: implementation science evaluation protocol. BMC Health Serv Res. 2023;23(1):503. doi:10.1186/s12913-023-09500-w

34.

Pilcher

Ospina-Norvell

Dasgupta

, et al. The effect of same-day observed initiation of antiretroviral therapy on HIV viral load and treatment outcomes in a US public health setting. J Acquir Immune Defic Syndr. 2017;74(1):44-51. doi:10.1097/QAI.0000000000001134

35.

Lightner

Chesnut

Cabral

, et al. Advancing patient navigation for HIV: evaluating models of care for housing and employment. AIDS Behav. 2024;28(11):3910-3918. doi:10.1007/s10461-024-04464-2

36.

Natale-Pereira

Enard

Nevarez

Jones

LA.

The role of patient navigators in eliminating health disparities. Cancer. 2011;117(15 Suppl):3543-3552. doi:10.1002/cncr.26264

37.

Landovitz

Desmond

Leibowitz

AA.

Antiretroviral therapy: racial disparities among publicly insured Californians with HIV. J Health Care Poor Underserved. 2017;28(1):406-429. doi:10.1353/hpu.2017.0031

38.

Park

Stockman

Thrift

Nicole

Smith

LR.

Structural barriers to women’s sustained engagement in HIV care in Southern California. AIDS Behav. 2020;24(10):2966-2974. doi:10.1007/s10461-020-02847-9

39.

Adimora

Auerbach

JD.

Structural interventions for HIV prevention in the United States. J Acquir Immune Defic Syndr. 2010;55(Suppl 2):S132-S135. doi:10.1097/QAI.0b013e3181fbcb38

40.

Milloy

Marshall

Montaner

Wood

Housing status and the health of people living with HIV/AIDS. Curr HIV/AIDS Rep. 2012;9(4):364-374. doi:10.1007/s11904-012-0137-5

41.

Aidala

Wilson

Shubert

, et al. Housing status, medical care, and health outcomes among people living with HIV/AIDS: a systematic review. Am J Public Health. 2016;106(1):e1-e23. doi:10.2105/AJPH.2015.302905

42.

Riley

Vittinghoff

Koss

, et al. Housing first: unsuppressed viral load among women living with HIV in San Francisco. AIDS Behav. 2019;23(9):2326-2336. doi:10.1007/s10461-019-02601-w

43.

Darlington

Hutson

SP.

Understanding HIV-related stigma among women in the Southern United States: a literature review. AIDS Behav. 2017;21(1):12-26. doi:10.1007/s10461-016-1504-9

44.

Scofield

Moseholm

HIV-related stigma and health-related quality of life in women living with HIV in developed countries: a systematic review. AIDS Care. 2022;34(1):7-15. doi:10.1080/09540121.2021.1891193

45.

Rao

Andrasik

Lipira

HIV stigma among Black women in the United States: intersectionality, support, resilience. Am J Public Health. 2018;108(4):446-448. doi:10.2105/AJPH.2018.304310

46.

Centers for Disease Control and Prevention. About AtlasPlus. December 2024. Accessed July 8, 2025. https://www.cdc.gov/nchhstp/about/atlasplus.html