The HIV/AIDS Epidemic in the United States

Jennifer Kates, M.A., M.P.A. Vice President and Director, HIV Policy Kaiser Family Foundation

KaiserEDU.org Tutorial February 2006

Figure 1

The U.S. Epidemic: Snapshot of Key Data

New infections each year People living with HIV/AIDS People with HIV/AIDS not in care People with HIV who dont know theyre infected 40,000 1,039,000 1,185,000 42 59%

24 27%

Note: Data are estimates. Sources: CDC, 2005; Glynn, K. et al., CDC, "Estimated HIV prevalence in the United States at the end of 2003", Presentation at the National HIV Prevention Conference, 2005; Fleming, P., et al., HIV Prevalence in the United States 2000, 9th Conference on Retroviruses and Opportunistic Infections, 2002.

Figure 2

New AIDS Cases, Deaths, and People Living with AIDS, 1985-2004
Deaths and New AIDS Diagnoses

85,000 68,000 51,000 34,000

New AIDS Cases

People Living with AIDS

420,000

People Living with AIDS

280,000

140,000 17,000 0
Deaths among People with AIDS

0 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2004

Note: Data are estimates. Source: CDC, Data Request, 2006.

Impact on Communities of Color

Figure 3

Proportion of AIDS Cases, by Race/Ethnicity, 1985-2004

Percent of AIDS Diagnoses

70 60 50 40
African American White, non-Hispanic

30 20 10 0
1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2004

Latino Asian/Pacific Islander

American Indian/ Alaska Native

Note: Data are estimates. Source: CDC, Data Request, 2006.

Figure 4

AIDS Diagnoses and Population, by Race/Ethnicity, 2004

AIDS Cases 42,514 U.S. Population 293,655,404 White, non-Hispanic

28%

69%

African American
49% 13% 14% 4% 1%

Latino 20% <1% Asian/Pacific Islander 1% AI/AN

Notes: U.S. Population estimates do not include U.S. dependencies, possessions, and associated nations; persons who reported more than one race were included in multiple categories. May not total 100% due to rounding. Total AIDS diagnoses in 2004 include persons of unknown race or multiple races. AI/AN = American Indian/Alaskan Native Sources: CDC, HIV/AIDS Surveillance Report, Vol. 16, 2005; U.S. Census Bureau, Population Estimates Program, 2004 Population Estimates.

Impact on Women

Figure 5

Women as a Share of New AIDS Diagnoses

27% 20% 13% 8% 27%

1985

1990

1995

2000

2004

Note: Data are estimates. Sources: CDC, Data Request, 2006.

Figure 6

New AIDS Diagnoses by Race/Ethnicity and Sex, 2004

1% Other 2% Other

17% White

15% Latina

67% African American

33% White

44% African American 20% Latino

Women N = 11,109

Men N = 30,203

Note: Data are estimates for adults/adolescents and do not include cases from the U.S. dependencies, possessions, and associated nations, and cases of unknown residence. Source: CDC, HIV/AIDS Surveillance Report, Vol. 16, 2005.

Figure 7

Reported HIV Cases Among Teen Girls and Younger Women, 2003

50%

63%

71% Males Females

50%

37%

29%

13-19

20-24

25 and older

Notes: Data based on persons age at diagnosis, from 41 areas with confidential name-based HIV surveillance for adults and adolescents in 2003. Source: CDC, HIV/AIDS Surveillance in Adolescents, L265 Slide Series Through 2003.

Figure 8

HIV Spread Primarily Through Sex, Increasingly Heterosexual

Heterosexual

3%
13% Other 19% IDU 65% MSM 6% Other 22% IDU

31% Heterosexual 42% MSM

1985

2004

Notes: Data are estimates. May not total 100% due to rounding. Sources: CDC, Presentation by Dr. Harold Jaffe, HIV/AIDS in America Today, National HIV Prevention Conference, 2003; CDC, HIV/AIDS Surveillance Report, Vol. 16, 2005.

Regional, State, & Local Impact

Figure 9

AIDS Case Rate per 100,000 Population by Region, 2004

6.8

9.0 18.7 20.4

Midwest West South Northeast

Notes: Case rates calculated by KFF; data do not include U.S. territories and possessions. Sources: CDC, HIV/AIDS Surveillance Report, Vol. 16, 2005; U.S. Census Bureau, Population Estimates Program, 2004 Population Estimates.

Figure 10

Top 10 States by AIDS Case Rate per 100,000 Population, 2004

District of Columbia New York Florida Maryland Puerto Rico 39.7 33.5 26.1 23.4
U.S. Rate = 15.0

179.2

Louisiana 22.4 New Jersey 21.2

Delaware 18.9 Georgia 18.6 Connecticut & Virgin Is. 18.4

Source: CDC, HIV/AIDS Surveillance Report, Vol. 16, 2005.

Figure 11

Top 10 States by AIDS Case Rate per 100,000 African Americans, 2004
District of Columbia New York Florida North Dakota New Hampshire New Jersey Maryland Rhode Island Pennsylvania Delaware 158.7 148.7 131.1 114.7 110.2 92.6 86.9 84.6 77.1
U.S. Rate = 73.9

335.1

Note: Data not available for U.S. dependencies, possessions, and independent nations in free association with the United States. Source: Kaiser Family Foundation, State Health Facts (CDC, Special Data Request, November 2005).

Figure 12

Top 10 States by AIDS Case Rate per 100,000 Among Women, 2004
District of Columbia New York Florida Maryland Delaware New Jersey Louisiana Connecticut Puerto Rico Virgin Islands 29.3 23.1 22.5 17.8 16.8 16.3 16.2 15.7 13.4
U.S. Rate = 9.5

113.3

Source: Kaiser Family Foundation, State Health Facts (CDC, Special Data Request, November 2005).

Figure 13

Top 10 MSAs by AIDS Case Rate per 100,000 Population, 2004

Miami, FL New York, NY Baton Rouge, LA Washington DC-MD-VA-WV Baltimore, MD New Orleans, LA Poughkeepsie, NY Orlando, FL Jackson, MS Jacksonville, FL
Note: MSAs with 500,000 or more population. Source: CDC, HIV/AIDS Surveillance Report, Vol. 16, 2005.

53.8 41.9 35.0 35.0 32.8 31.9 31.3 31.2 30.0 29.9
U.S. Rate = 15.0

Federal Funding of Health Care and Prevention Services for HIV/AIDS

Figure 14

Federal Funding for HIV/AIDS by Category, FY 2005

US$ Billions
Research $2.9 (15%) Global* $2.3 (12%) Prevention, $0.9 (4%) Cash/ Housing Assistance $1.9 (9%)

Care $11.7 (59%)

Total: $19.7 billion

*Not including international research which is counted in the research and prevention categories. Sources: Kaiser Family Foundation, Federal Funding for HIV/AIDS: The FY 2006 Budget Request, 2/05; DHHS, Office of Budget/ASBTF, 2/05; SSA, Office of the Actuary, 4/05; CMS, Office of the Actuary, 2/05; State Department, Office of the Global AIDS Coordinator; U.S. Congress, FY 2005 Consolidated Appropriations Bill and Conference Report.

Figure 15

Major Federal Sources of Funding for HIV/AIDS Care Medicaid Medicare

Ryan White CARE Act

Others include: Department of Veterans Affairs; SAMHSA; Community and Migrant Health Centers
Sources: Kaiser Family Foundation, Financing HIV/AIDS Care: A Quilt with Many Holes, May 2004; DHHS, Office of Budget/ASBTF, 4/05.

Figure 16

Medicaids Role in HIV/AIDS Care

Federal Medicaid Spending on Provides health & long-term care coverage for more than 52 M HIV/AIDS Care as Percent of Federal low-income people Spending on HIV/AIDS Care FY 2005 Largest source of coverage for people with HIV/AIDS 250,000 Medicaid beneficiaries with HIV/AIDS Medicaid Reflects epidemics impact on low-income populations 49% All Other Medicare ($5.7B) 51% ($6.0B) Many with HIV/AIDS qualify through disability-related pathway

Total: $11.7 B

Mandatory and Optional Services All states cover Rx drugs

Sources: Kaiser Family Foundation, Medicare and HIV/AIDS, 9/05; KCMU, The Medicaid Program at a Glance, 1/05. Medicaid HIV/AIDS spending estimate from CMS, Office of the Actuary, 2005, and HHS Office of the Budget, 2005.

Figure 17

Medicares Role in HIV/AIDS Care

Medicare Spending on HIV/AIDS Care as Percent of Federal Spending on HIV/AIDS Care FY 2005
Covers nearly 42 M seniors and persons with disabilities Second largest source of HIV/AIDS coverage 100,000 Medicare beneficiaries with HIV/AIDS, Many have supplemental assistance, including Medicaid and ADAP to pay for drugs New Medicare Part D Drug Coverage Concerns about adequacy of formularies and transition of Dual Eligibles (ARVs yes, other Rx?) Effect on ADAP?

Medicaid Medicare 25% ($2.9B) All Other 75%($8.8B)

Total: $11.7 B

Sources: Kaiser Family Foundation, Medicare and HIV/AIDS, 9/05; Kaiser Family Foundation, Medicare at a Glance, 9/05. Medicare HIV/AIDS spending estimate from CMS, Office of the Actuary, 2005, and HHS Office of the Budget, 2005.

Figure 18

The Ryan White CARE Act

Original intent: relief to safety net (public hospitals) Important safety-net for uninsured and low-income individuals Discretionary program, not entitlement Only disease-specific discretionary grant program for care for people with HIV/AIDS Builds on Medicaid Gap filler in terms of eligibility AND services Services provided include: comprehensive primary care support services, medications What you get depends on where you live $2.1 B in FY 2005

Figure 19

Components of the CARE Act

ADAP Clients, by Income Level, June 2004 >300% FPL 5% 201-300% FPL, 11% 101-200% FPL 29% <100% FPL 51% Unknown 3% Title I: Eligible Metropolitan Areas (Cities) Title II: Funding to States Includes earmark for AIDS Drug Assistance Program (ADAP) Title III: Funds early intervention services, capacity building, planning Title IV: Funds Services for Women, Youth, Children, Infants Other Funding for: AIDS Education and Training Centers, Dental Services, Special Projects of National Significance
Sources: DHHS, HRSA, HIV/AIDS Bureau; KFF, NASTAD, National ADAP Monitoring Report, April, 2005.

Figure 20

HIV Prevention
HIV Prevention Funding at CDC, FY 1995-2005 (US $ Millions) Centers for Disease Control and Prevention (CDC) Most prevention funding Funds go to states; some cities; community based organizations; other entities/programs

1995 1997 1999Medicare 2001Ryan

White 2003

$589.8
All Other 51% ($6.0B) $656.6

$616.8

Additional prevention funding also at: Department of Veterans Affairs, SAMHSA, $749.7 and other agencies

$793.6 $731.7

2005

National HIV prevention goal (reduce new infections by 50% by 2005) was not met

Sources: CDC, Personal Communication, 2006; CDC, HIV Prevention Strategic Plan Through 2005.

Figure 21

CDCs Advancing HIV Prevention: New Strategies for A Changing Epidemic

Announced in 2003 Aims to:
reduce barriers to early diagnosis of HIV increase access to quality medical care, treatment, and ongoing prevention services for with HIV.

Four Main Strategies

Incorporate HIV testing as a routine part of care in traditional medical settings Implement new models for diagnosing HIV infections outside medical settings (e.g., rapid testing) Prevent new infections by working with people diagnosed with HIV and their partners Further decrease mother-to-child HIV transmission
Sources: CDC, Advancing HIV prevention: New strategies for a changing epidemic. MMWR 2003;52:329-332; CDC, AHP: http://www.cdc.gov/hiv/prev_prog/AHP/default.htm.

Figure 22

Key Summary Points about the Domestic Epidemic

Approaching 25 years of AIDS

Tremendous successes in the U.S. including

significant reduction in new infections since the 1980s antiretroviral treatment and people living longer reduction in mother to child transmission

But the U.S. epidemic is not over - troubling signs, potential increases among some populations
Impact varies across country complex & local
Minority Americans, particularly African Americans, women, young people, men who have sex with men

Many challenges remain for prevention, care, treatment, and research