Overview

The HIV epidemic in New York City continues to be concentrated among men who have sex with men (MSM). Although new HIV diagnoses fell by 50% and most subpopulations experienced declines from 2001 to 2014, new diagnoses only decreased by 5% among MSM during this period.[1] Despite the wide availability of effective and well-tolerated antiretroviral medications, the prevention and care benefits of antiretroviral therapy are improving but have not yet been maximized. In 2014, 74% of MSM living with HIV infection in New York City were virally suppressed.

With its different neighborhoods and communities, New York City is a microcosm of the United States and the world. Distinct regional patterns to HIV risk and infections throughout New York City approximate experiences in other jurisdictions. As such, many lessons learned in New York City are adaptable to other cities, states, or countries.

MSM living in New York City are also at risk for sexually transmitted infections (STIs) other than HIV infection. For example, in 2014, 97% of cases of primary and secondary syphilis were among men; of those interviewed, 79% reported having sex with another man.[2] Data from New York City indicate that HIV incidence rates are extremely high among MSM who were recently diagnosed with syphilis, rectal gonorrhea, or chlamydia.[3,4]

HIV infection is a major and persistent health threat in New York City; similar to other US jurisdictions, the greatest incidence of HIV infection occurs among MSM, particularly MSM of color. HIV surveillance data demonstrate profound disparities among HIV-infected persons based on gender, sexuality, and race or ethnicity. Decades after the first local cases of HIV infection were described in New York City, the scale of the local HIV epidemic among MSM continues to be sizeable: 46,153 MSM are presumed to be living with HIV infection, including 27,707 MSM of color (black, Latino, or Hispanic). Of the 2718 New York City residents newly diagnosed with HIV infection in 2014, 1620 (60%) were men with a documented history of sex with men. Of MSM newly diagnosed with HIV infection in 2014, 1124 (69%) were black or Hispanic. Nearly 50% of MSM diagnosed with HIV infection in 2014 were aged 13 to 29 years.[1]

National data indicate that MSM make up approximately 60% of the 1.2 million people living with HIV infection in the United States and 66% of all new HIV infections each year. The Centers for Disease Control and Prevention (CDC) estimates that only 4% of men in the United States are MSM, and the rate of new HIV diagnoses among MSM in the United States is more than 44 times that of men who are not MSM (range, 522–989/100,000 MSM vs 12/100,000 men who are not MSM).[5] A recent analysis from the CDC indicated that MSM in the United States have a 1 in 9 lifetime risk of HIV infection; black MSM are estimated to have a 1 in 2 lifetime risk of HIV infection.[6] HIV infection continues to be a substantial public health threat to MSM in New York City and across the United States.

Less is known about the epidemiology of HIV disease and STIs among transgender persons living in New York City, although an observational study found a high prevalence of HIV infection among transgender women, particularly those of color.[7] There are approximately 40 new HIV diagnoses per year among New York City residents who identify as transgender, the vast majority of whom are transgender women who have sex with men and are black or Hispanic. New York City continues to refine its epidemiologic understanding of HIV among transgender individuals through ongoing field services and specific analyses of epidemiologic data among non–gender conforming individuals.[1,8]

Although the statistics seem numerically large, trends in New York City demonstrate that new HIV infections continue to decrease (Figure 1).

Figure 1. New diagnoses of HIV infection in New York City by absolute number and incidence per 100,000 population. Adapted from New York State Department of Health and Mental Hygiene.[9]

Many New York City residents living with HIV infection are engaged in care, are on antiretroviral therapy, and are virally suppressed, leading to better health outcomes (Figure 2).

Figure 2: New York City HIV care continuum in 2014. ART indicates antiretroviral therapy. Adapted from New York State Department of Health and Mental Hygiene.[10]

Figure 3. HIV care continuum in the United States. Adapted from AIDS.gov.[11]

Recent trends indicate that more individuals with newly diagnosed HIV infection are initiating antiretroviral therapy earlier and that a high proportion are achieving viral load suppression within 12 months of diagnosis. In 2008, 36% of individuals newly diagnosed with HIV infection achieved viral suppression by month 12, compared with 64% in 2013 (Figure 4).

Figure 4: Time to viral suppression of individuals newly diagnosed with HIV infection in New York City from 2008 to 2013.ng>

Successes in ending HIV infection in some populations offer hope and strategies for addressing some of the more stubborn aspects of the New York City HIV epidemic. Figure 5 illustrates the surveillance view of the history of the New York City HIV epidemic.

Figure 5: History of the HIV epidemic in New York City from 1981 to 2014. Adapted from New York Department of Health and Mental Hygiene.[1]

In Figure 5, the curve of the epidemic has experienced 2 “bends” toward resolution. The first bend in the mid-1990s demonstrates precipitous decreases in new AIDS diagnoses and HIV-related deaths. Although syringe-exchange programs and other social interventions may have contributed to this decrease, the majority of the effect is likely attributable to the dawn of the era of potent antiretroviral therapy; disease progression slowed and AIDS-related deaths decreased. The second bend, however, is more subtle. In 2000, New York State reporting laws changed to include reports of all HIV diagnoses rather than just reports of AIDS diagnoses based on opportunistic infections or low CD4+ cell counts. The black line on the chart represents new HIV diagnoses. The slope of the curve demonstrates a slow bend downward compared with the dramatic bend seen with the introduction and scale-up of effective therapy. Embedded in this bend are some of the greatest successes against the New York City and New York State HIV epidemic: the near elimination of mother-to-child transmission and transmission through shared injection devices. The lessons from these successes are crucial in designing a strategy to further accelerate the bend in the New York City curve. Use of prenatal and antenatal PEP in pregnant women has resulted in the near or complete elimination of maternal transmission of HIV in New York (New York State, personal communication, December 1, 2015).

Similarly, harm-reduction strategies such as syringe-exchange programs and opiate replacement therapy have brought HIV transmission through injection drug use to a near halt.[1] With nearly 80% of HIV transmissions attributed to sexual contact in 2014, other harm-reduction strategies are needed to supplement the more than 36 million condoms distributed to New York City residents annually.[12] Data that support treatment as prevention[13] and PrEP[14-16] create a scientific possibility of reducing sexual transmission of HIV, even in individuals who do not use condoms consistently and especially in MSM. Recent data indicate a drastic reduction in condom efficacy when use is inconsistent.[17] Subgroup analyses of certain populations in the New York City epidemic demonstrate substantial reductions in new HIV diagnoses in almost all groups, but HIV infection among MSM remains stable. Historically, condoms have likely prevented thousands of infections, but they are not adequate as a sole intervention to bend the epidemic curve at an adequate rate to bring an end to the growth of HIV infection in New York City.

The convergence of community activism and new science that supports the role of biomedical treatment and prevention technologies in a politically supportive environment has led New York City to work toward a goal of ending the HIV epidemic by 2020. The process officially began on June 29, 2014, when Governor Andrew M. Cuomo announced a 3-point plan to end the New York AIDS epidemic by 2020.[18] This announcement was the culmination of long hours of powerful advocacy from the community. The ultimate goal of this plan is to reduce the annual incidence of new HIV infections in New York State to approximately 750 infections from the current 3000 infections, at which point the total number of new infections will be less than the number of HIV-related deaths. Prevalence of HIV infection will decrease in New York State for the first time. For New York City, this means decreasing new HIV diagnoses to 600 or fewer to achieve this goal. This statewide plan comprises 3 pillars that address the core interventions needed to end the HIV epidemic:

• Identify persons with HIV infection who remain undiagnosed and link them to health care.
• Link HIV-infected persons to and retain them in health care, and prescribe them anti-HIV therapy to maximize viral suppression and prevent further transmission.
• Provide access to PrEP for those at risk of HIV infection in order to keep them HIV seronegative.

These 3 pillars were presented in the New York State Blueprint to End the AIDS Epidemic (EtE), a document compiled through extensive community engagement that included many stakeholders from New York City government and community. This EtE strategy builds on progress made in New York State that has led to a 53% reduction in new HIV infections between 2001 and 2013, as well as the implementation of key policies enacted in 2016 that support the goals of this initiative.

On World AIDS Day, December 1, 2015, New York City Mayor Bill de Blasio announced an additional $23 million in city budget funds to implement the strategy developed in the Blueprint via programs and interventions based in science and designed in close collaboration with the New York City community. New York State has supported many new options for providing coverage for health care to individuals who had previously been uninsured.

Leveraging these opportunities by linking people with HIV infection or who are at risk of exposure to HIV to health care that is sensitive to their needs is a cornerstone of the New York City strategy to translate recommendations into actionable interventions.

City funding will support the following initiatives:

• Promotion of early initiation of antiretroviral therapy in individuals newly diagnosed with HIV infection and maintenance of viral suppression in those with established HIV disease.
• Initiation of PrEP and PEP for eligible patients in New York City Department of Health and Mental Hygiene sexually transmitted disease (STD) clinics with potential exposures to HIV, and support for a robust network of community partners to further extend preventive interventions.
• Expansion of STD clinic services: enhanced funding for Health Department STD clinics to expand hours and service delivery capabilities, conduct community outreach and social mobilization to potential consumers of these services, and work across the entire health care delivery system to create a more welcoming environment for lesbian, gay, bisexual, transgender, and queer communities.
• Implementation of molecular epidemiology and further expansion of field services to rapidly address clusters of new HIV infections and to offer HIV care and preventive services with more efficiency and specificity.

The following Cases on the Web (COW) activity will explore the vision and strategies of New York State and City to achieve the goal of ending the HIV epidemic in New York City and New York State by 2020.