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

New infections each year 40,000 People living with HIV/AIDS 1,039,000 – 1,185,000 People with HIV/AIDS not in care 42 – 59% People with HIV who don’t know they’re infected 24 – 27% The U.S. Epidemic: Snapshot of Key Data 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”, 9 th Conference on Retroviruses and Opportunistic Infections, Figure 1

New AIDS Cases People Living with AIDS New AIDS Cases, Deaths, and People Living with AIDS, Deaths among People with AIDS Note: Data are estimates. Source: CDC, Data Request, Figure 2 Deaths and New AIDS Diagnoses People Living with AIDS 2004

Impact on Communities of Color

Proportion of AIDS Cases, by Race/Ethnicity, White, non-Hispanic African American Latino Asian/Pacific Islander American Indian/ Alaska Native Percent of AIDS Diagnoses Note: Data are estimates. Source: CDC, Data Request, Figure

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. 1% 4% AIDS Diagnoses and Population, by Race/Ethnicity, % 13% 28% 69% 20% 14% White, non-Hispanic African American Latino Asian/Pacific Islander AI/AN <1% 1% AIDS Cases 42,514 U.S. Population 293,655,404 Figure 4

Impact on Women

Women as a Share of New AIDS Diagnoses Note: Data are estimates. Sources: CDC, Data Request, Figure 5

New AIDS Diagnoses by Race/Ethnicity and Sex, % White 15% Latina Women N = 11,109 Men N = 30,203 67% African American 17% White 1% Other 20% Latino 44% African American 2% Other 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, Figure 6

Reported HIV Cases Among Teen Girls and Younger Women, 2003 Notes: Data based on person’s age at diagnosis, from 41 areas with confidential name-based HIV surveillance for adults and adolescents in Source: CDC, HIV/AIDS Surveillance in Adolescents, L265 Slide Series Through Figure 7

HIV Spread Primarily Through Sex, Increasingly Heterosexual % IDU 65% MSM 13% Other 3% 31% Heterosexual 22% IDU 42% MSM 6% Other 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, Figure 8 Heterosexual

Regional, State, & Local Impact

AIDS Case Rate per 100,000 Population by Region, 2004 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 9

Top 10 States by AIDS Case Rate per 100,000 Population, 2004 U.S. Rate = 15.0 Source: CDC, HIV/AIDS Surveillance Report, Vol. 16, Figure 10

Top 10 States by AIDS Case Rate per 100,000 African Americans, 2004 U.S. Rate = 73.9 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 11

Top 10 States by AIDS Case Rate per 100,000 Among Women, 2004 U.S. Rate = 9.5 Source: Kaiser Family Foundation, State Health Facts (CDC, Special Data Request, November 2005). Figure 12

Top 10 MSAs by AIDS Case Rate per 100,000 Population, 2004 U.S. Rate = 15.0 Note: MSAs with 500,000 or more population. Source: CDC, HIV/AIDS Surveillance Report, Vol. 16, Figure 13

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

Federal Funding for HIV/AIDS by Category, FY 2005 *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. US$ Billions Total: $19.7 billion Figure 14

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 Figure 15 Sources: Kaiser Family Foundation, Financing HIV/AIDS Care: A Quilt with Many Holes, May 2004; DHHS, Office of Budget/ASBTF, 4/05.

Provides health & long-term care coverage for more than 52 M low-income people Largest source of coverage for people with HIV/AIDS  ≈250,000 Medicaid beneficiaries with HIV/AIDS  Reflects epidemic’s impact on low-income populations Many with HIV/AIDS qualify through disability-related pathway Mandatory and Optional Services  All states cover Rx drugs Medicare Medicaid’s Role in HIV/AIDS Care Figure 16 Federal Medicaid Spending on HIV/AIDS Care as Percent of Federal Spending on HIV/AIDS Care FY 2005 Medicaid 49% ($5.7B) All Other 51% ($6.0B) Total: $11.7 B 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.

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’s Role in HIV/AIDS Care 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, Figure 17 Medicare Spending on HIV/AIDS Care as Percent of Federal Spending on HIV/AIDS Care FY 2005 Total: $11.7 B Medicare 25% ($2.9B) All Other 75%($8.8B)

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 18

Components of the CARE Act 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 Figure 19 ADAP Clients, by Income Level, June 2004 Sources: DHHS, HRSA, HIV/AIDS Bureau; KFF, NASTAD, National ADAP Monitoring Report, April, <100% FPL 51% % FPL 29% % FPL, 11% Unknown 3%>300% FPL 5%

HIV Prevention Centers for Disease Control and Prevention (CDC)  Most prevention funding  Funds go to states; some cities; community based organizations; other entities/programs Additional prevention funding also at: Department of Veterans Affairs, SAMHSA, and other agencies National HIV prevention goal (reduce new infections by 50% by 2005) was not met Medicare Ryan White Figure 20 HIV Prevention Funding at CDC, FY (US $ Millions) All Other 51% ($6.0B) Sources: CDC, Personal Communication, 2006; CDC, HIV Prevention Strategic Plan Through $731.7 $589.8 $616.8 $656.6 $749.7 $793.6

CDC’s “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 Figure 21 Sources: CDC, Advancing HIV prevention: New strategies for a changing epidemic. MMWR 2003;52: ; CDC, AHP:

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 Figure 22