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HIV Care and Treatment of American Indians/Alaska Natives With Int J STD AIDS OnlineFirst, published on November 21, 2016 as doi:10.1177/0956462416681183 Original research article International Journal of STD & AIDS 0(0) 1–9 ! The Author(s) 2016 HIV care and treatment of American Reprints and permissions: sagepub.co.uk/journalsPermissions.nav Indians/Alaska natives with diagnosed DOI: 10.1177/0956462416681183 std.sagepub.com HIV infection – 27 states and the District of Columbia, 2012 Andrew Mitsch1, Aruna Surendera Babu1,2, Dean Seneca3, Y Omar Whiteside1 and Donald Warne4 Abstract The objective of this study was to measure linkage to care, retention in care, and suppressed viral load (VL) among American Indians/Alaska Natives (AIs/ANs) aged 13 years with diagnosed HIV infection. We used national HIV case surveillance data to measure linkage to care, defined as 1 CD4 or VL test 1 month after HIV diagnosis during 2013; retention in care, defined as 2 CD4 or VL tests 3 months apart during 2012; and suppressed VL, defined as <200 copies/mL at the most recent VL test during 2012. In 2013, 74.1% of AIs/ANs were linked to care. At year-end 2012, 46.9% of AIs/ANs were retained in care and 45.1% were virally suppressed. A lower percentage of females (41.3%), compared with males (46.5), were virally suppressed. By age group, the lowest percentage of virally suppressed AIs/ANs (37.5%) were aged 13–34 years. To improve individual health and to prevent HIV among AIs/ANs, outcomes must improve – particularly for female AIs/ANs and for AIs/ANs aged 13–34 years. Screening for HIV infection in accordance with Centers for Disease Control and Prevention’s testing recommendations can lead to improvements along the continuum of HIV care. Keywords Epidemiology, highly active antiretroviral therapy, HIV, North America, prevention Date received: 10 June 2016; accepted: 24 October 2016 In response to endemic HIV infection in the United promote the health status of AIs/ANs in exchange for States, the White House developed the National HIV/ vast land cessions that undermined the basis of trad- AIDS Strategy (NHAS), which proposed ‘The United itional living;4 and AIs/ANs are among populations at States will become a place where new HIV infections risk but that have a low national burden of HIV, and are rare and when they do occur, every person ...will therefore in need of high-impact prevention to achieve have unfettered access to high quality, life-extending 1 care, free from stigma and discrimination.’ Data 1Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral from the National HIV Surveillance System (NHSS) Hepatitis, STD, and TB Prevention, Centers for Disease Control and 2 are used to measure progress toward NHAS goals Prevention, Atlanta, GA, USA and may be used to compare established objectives 2ICF Macro International, Inc., Corporate Square, Atlanta, GA, with HIV care and treatment outcomes among all resi- USA 3Office for State, Local, Territorial and Tribal Support, Office of the dents of the US, including American Indians/Alaska Director, Centers for Disease Control and Prevention, Atlanta, GA, USA Natives (AIs/ANs). 4Department of Public Health, College of Health Professions, North Our study focuses on AIs/ANs because: representa- Dakota State University, Fargo, ND, USA tives from AI/AN communities have called on the Centers for Disease Control and Prevention Corresponding author: Andrew Mitsch, Centers for Disease Control and Prevention, Division of (CDC) to improve the quality of HIV surveillance 3 HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, data and use the data to inform public health action; STD and TB Prevention, 8 Corp. Sq. MS E-47, Atlanta, GA 30324, USA. the US Government assumed a ‘trust responsibility’ to Email: [email protected] Downloaded from std.sagepub.com by guest on November 22, 2016 2 International Journal of STD & AIDS 0(0) NHAS goals (The White House Office of National prognoses than do those at a less severe stage of infec- AIDS Policy,1 p.19). AIs/ANs are defined as persons tion at diagnosis.19 In 2014, approximately 20% of having origins in any of the original peoples of North, diagnoses of HIV infection among AIs/ANs were clas- South, or Central America and who maintain tribal sified as stage 3 (AIDS) (compared with 24% among affiliation or community attachment.5 Because NHSS all race/ethnicity groups combined). By race, a care adheres to the US Office of Management and Budget continuum analysis of women living with diagnosed standards for collection of race data, and NHSS uses HIV infection at year-end 2011 showed that AI/AN US Census data to determine population sizes, we use women had the least favorable viral suppression.20 the term ‘AIs/ANs’ as defined by the US Census. Inequities also include high rates of sexually trans- Rather than using this term, others prefer alternatives mitted infections,21 a surrogate marker of elevated including ‘Native Americans’. HIV risk in a community and a facilitator of HIV trans- The HIV Care Continuum Initiative addresses suit- mission.22 During 2007–2010, higher chlamydia case able measurements of progress among AIs/ANs toward rates among AIs/ANs in 10 of 12 (83%) Indian NHAS goals.6 The five steps of the continuum are (1) Health Service (IHS) areas and higher rates of infec- diagnosis of HIV infection; (2) linkage to care; (3) tious syphilis in four (25%) IHS areas were reported retention in care; (4) prescription of antiretroviral compared with rates among all races/ethnicities (ARV) treatment; and (5) achievement of viral suppres- (Walker et al.,21 p.488). sion.7 Unfavorable measurements at any step in the Increasing trends in the estimated number of new continuum can negatively affect measurements at suc- diagnoses of HIV infection and prevalence among cessive steps. Indicators of progress in achieving NHAS AIs/ANs highlight the importance of achieving care goals for the care of persons living with diagnosed HIV continuum goals for this population. During 2010– infection include 85% linked to care within one 2014, the rates of diagnoses among AIs/ANs increased month after diagnosis; 90% retained in care; and from 7.8 per 100 000 to 9.5 per 100 000 (þ22%) in 80% virally suppressed (The White House Office of the US (CDC,17 p.18). By transmission category National AIDS Policy,1 p.49–57). Measuring and among AIs/ANs, 65% (142) of diagnoses in 2014 monitoring these outcomes for AIs/ANs are recom- were attributed to male-to-male sexual contact, 21% mended actions of NHAS. Improved linkage to, and (46) to heterosexual contact, and 11% (24) to injection retention in, HIV care can lead to viral suppression drug use (CDC,17 p.26). By year-end 2013, about among AIs/ANs, thereby improving the quality of life 930,000 persons were living with diagnosed HIV infec- for those already infected,8 and decreasing the number tion, and the overall prevalence rate was 295.1 per 100 of new infections.9 000 US residents (CDC,11 p.100). By year-end 2013, According to the 2010 census, 2.9 million people in nearly 3000 AIs/ANs were living with diagnosed the United States indicated their race as AI/AN (alone, HIV infection, and the prevalence rate was 123.2 per not in combination with one or more other races). 100,000. The highest prevalence rate was among AIs/ANs represented approximately 1% of the general Blacks/African Americans (1018.1/100,000) and the population, similar to the proportion of persons with lowest among Asians (70.9/100,000). As evidenced by HIV reported to NHSS and classified as AI/AN.5,10 the number of new HIV diagnoses, AIs/ANs are becom- In NHSS, records indicating AI/AN race alone are clas- ing vulnerable to HIV infection (CDC,17 pp.18–21). sified as ‘AI/AN’ while records indicating AI/AN Using NHSS case surveillance data statistically race in combination with other races are classified as adjusted for missing risk factor information,23 we deter- ‘multiple races’ (CDC,11 p.4.3). During 2000–2010, the mined the numbers and percentages of adult and ado- rate of population growth among AIs/ANs (18%) was lescent (aged 13 years) AIs/ANs with diagnosed HIV nearly twice the rate of overall growth of the US popu- infection who were linked to HIV care, retained in care, lation (10%).5 and virally suppressed. Our objectives were to measure AIs/ANs experience multiple health inequities, linkage to care among AIs/ANs with HIV infection including elevated rates of tuberculosis, alcoholism, diagnosed during 2013 and retention in care and viral obesity (and diabetes), commercial tobacco use (and suppression among AIs/ANs whose infection had been cancer), unintentional injuries, homicide, and sui- diagnosed by year-end 2011 and who were living at cide.12–16 During 2005–2010, 79% of AIs/ANs year-end 2012, and to compare these outcomes with remained alive 36 months after a classification of HIV NHAS 2020 goals. infection, stage 3 (AIDS) (lowest of all races, and com- pared with 84% among all race/ethnicity groups com- Methods bined) (CDC,17 p.90). Patients with advanced immunosuppression (i.e. infection classified as stage 3 Because linkage to care is an event expected to happen [AIDS]18) at diagnosis of HIV infection have poorer swiftly after diagnosis and the number of included Downloaded from std.sagepub.com by guest on November 22, 2016 Mitsch et al. 3 jurisdictions increased over time, we only measured link- p.1339). If multiple VL tests were performed during the age for the most recent year available (2013).
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