The HIV/AIDS Epidemic in the United States
The first cases of what would later become known as AIDS were reported in the United States in June of 1981.1 Since then, more than 1.8 million people in the U.S. are estimated to have been infected with HIV, including over 650,000 who have already died; today, more than 1.1 million people are living with HIV.2,3 The response to the U.S. epidemic has yielded numerous successes, but challenges remain:
- While the number of new HIV infections (incidence) is down from its peak in the 1980s, new infections have remained at about 50,000 for more than a decade.4,5,6
- HIV testing is important for both prevention and treatment efforts and rapid testing is now much more widely available. Routine HIV testing is now recommended for all people ages 13-64,7 yet 16% of those infected with HIV don’t know it 3 and many people with HIV (32%) are diagnosed late in their illness.2
- Treatment advances have substantially reduced AIDS-related morbidity and mortality and extended the lives of many, and current U.S. HIV treatment guidelines recommend initiating antiretroviral therapy (ART) as soon as one is diagnosed with HIV.8 Still, many people with HIV are not in care, on treatment, or virally suppressed – the point at which the virus is under control and a person can remain healthy and reduce the risk of transmission.9
- The epidemic’s impact varies across the country, and it continues to have a disproportionate impact on certain populations, particularly racial and ethnic minorities and gay and bisexual men.
Overview and Key Trends
- HIV incidence was highest in the 1980s – reaching 130,000 – followed by declines, and has remained relatively stable since at about 50,000 new infections per year.5,6 More recently, new infections have decreased among women but increased among gay and bisexual men.5 Today, more people are living with HIV than ever before, as people are living longer with HIV disease and new infections remain relatively stable.3,5
|Figure 1: Key Snapshot of the U.S. Epidemic Today2,3,4,9|
- Despite advances in combating HIV, hundreds of thousands have already died from the disease, and cumulative deaths among people with AIDS reached 658,992 at the end of 2010.2 Still, HIV-related mortality rates, which rose steadily through the 1980s and peaked in 1995, have declined significantly; the age-adjusted HIV death rate has dropped by 85% since its peak, including by 14% between 2009 and 2010.10,11 This is largely due to ART but also to decreasing HIV incidence after the 1980s. In 2010, HIV was the 7th leading cause of death for those ages 25-44, down from #1 in 1994 and 1995.11
- HIV transmission patterns have shifted over time. Most new HIV infections occur through male-to-male sexual contact (63% in 2010) – an additional 3% of infections occurred among men who have sex with men (MSM) with a history of injection drug use – a smaller share than earlier in the epidemic. However, new infections among MSM increased between 2008 and 2010.4 Heterosexual sex has accounted for a growing share of transmissions over time, representing 25% of new infections in 2010. New infections due to injection drug use have declined significantly over time and accounted for 8% of new infections in 2010.4,5
- Medical advances and programs aimed at prevention and care have reached many people with or at risk for HIV, but looking across the spectrum from HIV diagnosis to viral suppression reveals missed opportunities for addressing the epidemic. While many people with HIV are diagnosed (82%) and linked to care (66%), far fewer remain in regular care (37%) and are prescribed ART (33%) Only one quarter (25%) are virally suppressed – a share that is even lower among Blacks (21%) and young people ages 25-34 (15%).9
Impact Across the Country
Although HIV has been reported in all 50 states, the District of Columbia, and U.S. dependencies, the impact of the epidemic is not uniformly distributed.
- Ten states accounted for about two thirds (65%) of HIV diagnoses in 2011 (Figure 2).2,12 Regionally, the South accounted for about half (48%) of HIV diagnoses in 2011.2
- Rates of HIV diagnoses per 100,000 provide a different measure of the epidemic’s impact, since they reflect the concentration of diagnoses after accounting for differences in population size across states. The District of Columbia has the highest rate in the nation, compared to other states, more than 9 times the national rate (Figure 2). Seven of the top 10 states by rate are in the South.12
- New HIV diagnoses are concentrated primarily in large U.S. metropolitan areas (81% in 2011), with New York, Los Angeles, and Miami topping the list.2
- Analyses of data from cities with high AIDS prevalence found that about 2% of heterosexuals were infected with HIV, and HIV prevalence was higher among those with less education and lower incomes.13,14
|Figure 2: Top Ten States/Areas by Number and Rate of New HIV Diagnoses, 20112,12|
|State||New HIV Diagnoses, Number (%)||State/Area||New HIV Diagnoses, per 100,000|
|California||5,965 (11.9%)||District of Columbia||177.9|
|Florida||5,394 (10.8%)||Virgin Islands||39.5|
|New York||4,944 (9.9%)||Maryland||36.4|
|Maryland||1,771 (3.5%)||New York||30.1|
|North Carolina||1,664 (3.3%)||Puerto Rico||28.6|
|New Jersey||1,557 (3.1%)||Mississippi||25.3|
|U.S. Total||50,007 (100%)||U.S. Rate||19.1|
Racial and Ethnic Minorities
Racial and ethnic minorities have been disproportionately affected by HIV/AIDS since the beginning of the epidemic, and represent the majority of new HIV infections, people living with HIV disease, and deaths among people with HIV.2,3,4
- Blacks and Latinos account for a disproportionate share of new HIV infections, relative to their size in the U.S. population.4,15
- There are more than 506,000 Blacks living with HIV in the U.S.3 Analysis of national household survey data found that 2% of Blacks in the U.S. were HIV positive, higher than any other group.16
- Blacks also have the highest rate of new HIV infections. In 2010, the rate of new HIV infections per 100,000 for Blacks (68.9) was about 8 times that of whites (8.7); Latinos (27.5) had a rate 3 times that of whites.4
- Blacks accounted for about half (48%) of deaths among people with an HIV diagnosis in 2010.2
- Survival after an AIDS diagnosis is lower for Blacks than for most other racial/ethnic groups, and Blacks have had the highest age-adjusted death rate due to HIV disease throughout most of the epidemic.2,10,11
- HIV was the 5th leading cause of death for Black men and the 7th for Black women, ages 25-44, in 2010, ranking higher than their respective counterparts in any other racial/ethnic group.11
Impact on Women and Young People
- More than 275,000 women are living with HIV in the U.S. today.3
- In 2010, women accounted for 20% (9,500) of new HIV infections, a 21% drop since 2008 and the first significant decrease after more than a decade of relatively steady HIV incidence.4,6
- Women of color are particularly affected, and in 2010, Black women accounted for nearly two thirds (64%) of new infections among women; Latinas accounted for 15% and white women 18%. Although there is a disproportionate impact on Black women, new infections among Black women decreased 21% between 2008 and 2010, driving the overall decrease among women.4
- Teens and young adults continue to be at risk, with those under 35 accounting for 56% of new HIV infections in 2010 (those ages 13-24 accounted for 26% and those ages 25-34 accounted for 31%).4 Most young people are infected sexually.17
- Among young people, minorities have been particularly affected. In 2010, 13-24 year-olds accounted for a greater share of newly infected Blacks (33%) and Latinos (24%) than they did among whites (16%). Young gay and bisexual men are also disproportionately affected.4
- Perinatal HIV transmission, from an HIV-infected mother to her baby, has declined significantly in the U.S., largely due to ART which can prevent mother-to-child transmission.2,18,19
Impact on Gay and Bisexual Men
- While estimates show that men who have sex with men (MSM) comprise only about 2% of the U.S. population, this group accounts for most new HIV infections (63% in 2010, with an additional 3% occurring in MSM with a history of injection drug use).4,5 Between 2008 and 2010, annual new HIV infections increased 12% among MSM.4
- Among MSM, whites accounted for the largest number of new infections (11,200) in 2010, followed by Blacks (10,600).4
- Younger MSM (ages 13-24) are at particular risk. In 2010, this group accounted for 1 in 5 (19%) of all new HIV infections and 30% of new infections among all MSM. Among Black MSM, this age group accounted for 45% of new infections.4
- New infections among MSM ages 13-24 increased by 22% between 2008 and 2010, the most significant increase of any age group.4
- A study in 20 major U.S. cities found that about 1 in 5 (18%) MSM is already living with HIV, with even higher prevalence among Black MSM, and many are unaware of their infection.20
The U.S. Government Response
- In FY 2014, U.S. federal funding to combat HIV totaled $29.5 billion. Of this, 55% was for care, 10% for cash and housing assistance, 9% for research, 3% for prevention, and 22% for the global epidemic.21
- Key programs that provide health insurance coverage, care, and support to people with HIV in the U.S. include Medicaid, Medicare, the Ryan White Program, and HOPWA, the Housing Opportunities for Persons with HIV/AIDS Program. Social Security’s income programs for those who are disabled (SSI and SSDI) are also important sources of support.
- A variety of federally and state-supported prevention services are provided by state and local health departments and community organizations.
- The passage of the Affordable Care Act in March 2010 provides new opportunities for expanding health care access, prevention, and treatment services for millions of people in the U.S., including many people with or at risk for HIV.22
- In July 2010, the U.S. government released the National HIV/AIDS Strategy, the first comprehensive plan for addressing the epidemic in the U.S.23 The strategy has three primary goals: reduce new HIV infections; increase access to care and improve health outcomes; and reduce HIV-related health disparities. To further address these, President Obama issued an Executive Order to establish an HIV Care Continuum Initiative in July 2013, and the Administration has begun to outline recommendations, develop action steps, and mark progress toward the goals set forth in the Initiative.24,25
CDC. MMWR, Vol. 30, No. 21; June 1981.
CDC. HIV Surveillance Report, Vol. 23; February 2013. HIV diagnosis data are estimates from all 50 states, the District of Columbia, and 6 U.S. dependent areas. Rates do not include U.S. dependent areas.
CDC. HIV Surveillance Supplemental Report, Vol. 18, No. 5; October 2013. Data are estimates and do not include U.S. dependent areas.
CDC. HIV Surveillance Supplemental Report, Vol. 17, No. 4; December 2012. Data are estimates and do not include U.S. dependent areas.
CDC. Fact Sheet: HIV in the United States; November 2013.
Hall HI et al. “Estimation of HIV Incidence in the United States.” JAMA, Vol. 300, No. 5; August 2008.
CDC. MMWR, Vol. 55, No. RR14; September 2006.
NIH. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents; last updated February 2013.
CDC. Fact Sheet: HIV in the United States: The Stages of Care; July 2012.
NCHS. Health, United States, 2012; May 2013.
CDC. Slide Set: HIV Mortality (through 2010).
CDC. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Atlas. Data are estimates from all 50 states, the District of Columbia, and 5 U.S. dependent areas.
CDC. MMWR, Vol. 60, No. 31; August 2011.
CDC. MMWR, Vol. 62, No. 10; March 2013.
U.S. Census Bureau. 2010 Population Estimates.
McQuillan GM et al. NCHS Data Brief, No. 4; January 2008 (ages 18-49).
CDC. Slide Set: HIV Surveillance in Adolescents and Young Adults (through 2011).
Nesheim S et al. “A Framework for Elimination of Perinatal Transmission of HIV in the United States.” Pediatrics, Vol. 130, No. 4; September 2012.
Whitmore SK et al. “Correlates of Mother-to-Child Transmission of HIV in the United States and Puerto Rico.” Pediatrics, Vol. 129, No. 1; January 2012.
Wejnert C et al. “HIV Infection and Awareness among Men Who Have Sex with Men – 20 Cities, United States, 2008 and 2011.” PLoS ONE, Vol. 8, No. 10; October 2013.
KFF analysis of data from OMB; April 2014.
KFF. The Affordable Care Act, the Supreme Court, and HIV: What Are the Implications? September 2012.
The White House. National HIV/AIDS Strategy for the United States; July 2010.
The White House. Executive Order – HIV Care Continuum Initiative; July 2013.
The White House. National HIV/AIDS Strategy – Improving Outcomes: Accelerating Progress Along the HIV Care Continuum; December 2013.