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U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 US Virgin Islands Epidemiology Profile for HIV/AIDS Prevention, Care, & Planning 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 All material contained in this document is in the public domain and may be used and copied without per- mission; citation of the source is, however, appreciated. Suggested citation Virgin Islands Department of Health—HIV Surveillance Program. Virgin Islands HIV Epidemiology Profile 2014. The profile is available at http://doh.vi.org U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Acknowledgements The Virgin Islands Department of Health HIV Surveillance Program would like to thank the following people for their valuable contribution to the researching and writing of this Epidemiology Profile. Annette Hobson—Territorial HIV Surveillance Specialist Latoya Harrigan—Walden University Student Practicum Ephthimios Doliotis—HIV Data Analyst Gritell Martinez Gary Smith Jason Henry Joscia Bassue Leslie Raymer Jeananne Cappeta Nadine Nader Debbie Castellano Graham Harrimar Amber Casey Jasper Lettsome Adrian Edwards Dr. Esther Ellis When we combine our skills, resources, and strengths, unite toward a common goal and collaborate to get results, we all get to share in the success! (Baudville) Thank you for your continued efforts in reducing the burden of HIV in the Virgin Islands. Page i U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Page ii Table of Contents Acknowledgements ....................................................................................................................................................................... i List of Abbreviations .................................................................................................................................................................... iii Executive Summary ..................................................................................................................................................................... iv Introduction .................................................................................................................................................................................1 Section 1: HIV and AIDS Epidemiology ........................................................................................................................................2 Question 1.1 | What are the socio-demographic characteristics of the general population in the US Virgin Islands? .............2 Question 1.2 | What is the scope of HIV Burden in the US Virgin Islands? .................................................................................7 Question 1.3 | What are the indicators of risk for HIV infection in the US Virgin Islands? .......................................................14 Section 2: Ryan White HIV/AIDS program .................................................................................................................................18 Question 2.1 | What is the impact of the care and treatment services of the Ryan White HIV/AIDS Program on people living with HIV in the US Virgin Islands? ....................................................................................................................18 Question 2.2 | What are some thing to keep in mind as a Ryan White HIV/AIDS Program grantee prepares the epidemiologic profile document for HRSA’s HIV/AIDS Bureau? ..........................................................................................24 Appendix: Data Tables ...............................................................................................................................................................27 Glossary ......................................................................................................................................................................................55 References ..................................................................................................................................................................................57 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Page iii List of Abbreviations ADAP – AIDS Drug Assistance Program AETC – AIDS Education and Training Centers Program AIDS – Acquired Immune Deficiency Syndrome BRFSS – Behavioral Risk Factor Surveillance System CDC – Centers for Disease Control and Prevention DHHS – Department of Health and Human Services eHARS – Enhanced HIV/AIDS Reporting System HAB – HIV/AIDS Bureau Hetero – Heterosexual HRSA – Health Resources and Services Administration HIV – Human Immunodeficiency Virus IDU – Injection Drug Use MMP – Medical Monitoring Project MSM – Male to male sexual contact NDI – No Determinate Infection NHAS – National HIV/AIDS Strategy NHBS – National HIV Behavioral Surveillance System NIR- No Identified Risk PLWHA – Persons Living With HIV/AIDS RWHAP – Ryan White HIV/AIDS Program SHADAC – State Health Access Data Assistance Center STD – Sexually Transmitted Disease USVI – United States Virgin Islands USVI BER – United States Virgin Islands Bureau of Economic Research VIDOH – Virgin Islands Department of Health YBRS – Youth Risk Behavioral Survey U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Page iv Executive Summary The 2014 US Virgin Islands Epidemiology Profile is composed of the following sections. Section 1 describes the sociodemographic characteristics of the general population in the US Virgin Islands, the human immuno- deficiency virus (HIV) infection epidemic, and indicators of HIV exposure or risk in the US Virgin Islands. Sec- tion 2 chronicles the care and treatment services provided by the Ryan White HIV/AIDS Program. An appen- dix, glossary, and references are included with this document. The appendix contains tables of all data pre- sented within the narrative as well as some additional data not described in the narrative. Readers may find it beneficial to review the information in the glossary first as it defines some of the key terms used in the doc- ument. The United States Virgin Islands (USVI) is unique among US states and territories in regards to HIV/AIDS epi- demiology. The USVI possesses a rather small population, and a fairly high HIV/AIDS infection rate. Blacks/ persons of African descent comprise most of the HIV/AIDS cases. However, it is also important to note the HIV infection continues to have a disproportionate impact on the Hispanic population. Also noteworthy, is the fact that the poverty rate in the USVI is almost double that of the national poverty rate. As a possible con- sequence of the poverty rate, the percentage of uninsured persons in the USVI is almost double that of the percentage of the US uninsured rate. As a result of these observations, the USVI Community Health Programs should retain and maintain activities on producing awareness about HIV/AIDS in the territory. Also important to note is the following indications about risk behaviors. The number of Chlamydia cases had increased from 2010. The number of gonorrhea cases in 2014, on the other hand, is lower than the 2012 level. Either way, these factors seem to indicate a significant amount of risky behavior taking place. Also on this note of risk behavior, heterosexual contact still remains as the leading cause of HIV infection for women in the USVI. In order to mitigate the HIV/AIDS epidemic in the USVI, efforts must focus on educating people concerning the facts regarding HIV/AIDS infection and treatment, promoting opportunities for testing and medical guid- ance, and locating HIV-positive people who are not in care. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Introduction The 2014 US Virgin Islands HIV/STD Epidemiologic Profile describes the epidemiology of the human immuno- deficiency virus (HIV) in the US Virgin Islands. The majority of data presented are drawn from surveillance systems maintained by the US Virgin Islands Department of Health (VI DoH), Division of Public Health, Com- municable Disease Branch. Throughout the profile, the following questions are addressed. 1. What are the sociodemographic characteristics of the general population in the US Virgin Islands? 2. What is the scope of HIV burden in US Virgin Islands? 3. What are the indicators of risk for HIV infection in the population of the US Virgin Islands? 4. What is the impact of the care and treatment services on people living with people living with HIV? Readers should also take note of the following: • HIV infection is defined as a diagnosis of HIV infection, regardless of the stage of infection (1, 2, 3, or un- known). In this report, applying the term “acquired immune deficiency syndrome” (AIDS) refers to HIV infec- tion Stage 3. AIDS is classified based on either CD4+ T-lymphocyte (CD4) cell count results or documentation of an AIDS-defining condition. • AIDS (Stage 3) classification is based on lab test or opportunistic infection and can be at the same time as HIV infection diagnosis or later, but once a person is classified as AIDS (Stage 3) (for surveillance purposes) they are always classified as AIDS (Stage 3). • HIV infection data are summarized by date of diagnosis. Chlamydia and gonorrhea data are presented by date of report. • References to race/ethnicity in this document may be different from those found in documents from other agencies. Unless otherwise noted, Hispanics are considered a separate racial/ethnic group. Thus, “white” re- fers to white non-Hispanic; “black” refers to black non-Hispanics, etc. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 SECTION 1 HIV and AIDS Epidemiology QUESTION 1.1 What are the sociodemographic characteristics of the general population in the US Virgin Islands? SOCIODEMOGRAPHIC INFORMATION The United States Virgin Islands (USVI), located between the Atlantic Ocean and the Caribbean Sea, consists of four islands; St. Croix, St. Thomas, St. John, and Water Island. The USVI covers approximately 133 square miles (combined land area), which is almost twice the area of Washington D.C. This U.S. Territory, is located 40 to 50 miles east of Puerto Rico and extends from west to east about 60 miles at the top of the arc of the other Caribbean Islands. POPULATION GROWTH TRENDS The USVI has a population of 106,405 spread over the four separate islands. The four islands, in descending order of population are St. Thomas, St. Croix, St. John, and Water Island. According to the U.S. Census Bu- reau, St. Thomas is approximately 32 square miles and had a population of 51,634 in 2010 which was an in- crease in population size of about 1% (453) than that reported in 2000. St. Croix is approximately 84 square miles and had a population of 50,601 in 2010. This is an almost 5% (2,633) decrease in population size from data reported in 2000. St. John, at 20 square miles, had a population of 4,170 which was a 0.6 % (27) de- crease compared to reports in 2000. Reported by the U.S. Census Bureau as a sub district of St. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Thomas, Water Island is approximately 491.5 acres in size and had a population of about 182 in 2010, which was included in the St. Thomas Census figures. The Water Island sub-district population decreased by 13% from 2000 to 2010. AGE According to the U.S. Census Bureau, the median age in 2010 (the age which half the population is older than and half is younger) was 39.2 years. This is an almost 6 year increase from the estimated median age of 33.4 years reported in 2000. This indicates that the USVI’s population is aging. In 2010, 17% (17,987) of the popu- lation was under the age of 13, and 15% (15,905) were 64 years and older. Approximately 37% (38,861) of the USVI population was over the age of 49 and 24% (26,050) of the population was between 25 to 44 years old. The age distribution varied slightly among the is- lands. St. Croix had the highest percent (14.1%) of the population over the age of 65 (7,089). Thirty percent (15,366) of the population in St. Croix was under the age of 19, followed by St. Thomas at 26% (13,425) and then St. John at 21.7%. GENDER According to the 2010 Census, 47.8% (50,867) of the USVI population were males and 52.2% (55,538) were females. Although percentages were very close, women slightly outnumbered men on each of the islands. In 2010, St. Croix males accounted for 47.8% (24,206) of the population whereas the females accounted for 52.2% (26,395). Females in St. Thomas accounted for 52.3 % (27,105) of the population and males made up 47.7% (24,619). St. John’s (2,128) female population was 51% and males accounted for 49% (2,042) of the population. RACE AND ETHNICITY In 2010, 66.1% of the USVI population (70,379) was black, and 13.5% or 14,352 reported as white. The popu- lation of St. Croix is comprised of 61.6% black and 11.3% white, whereas in St. John, 49.8% of the population reported as being black, and 37.1% as white, making St. John the island with the largest proportion of white individuals. Like St. John and St. Croix, 71.9% of the St. Thomas population reported as black and 13.7% re- ported as white. Overall, Hispanics represented 17.4 % (18,504) of the population, however, differences in the proportion of persons of Hispanic origin varied among the islands. St. Croix had the largest Hispanic pop- ulation among the other two islands at 24.3%. St. Thomas had 11.2% and St. John had the lowest reported number of Hispanics at 10.5%. 10,000 5,000 0 5,000 10,000 <13 13-14 15-24 25-34 35-44 45-54 55-64 >64 Population Population Pyramid of Age and Gender, VI (2010) Female Male A g e G r o u p U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 INSURANCE According to the 2010 Census, the number of uninsured US Virgin Islanders was 32,511, which is about 30% of the civilian noninstitutionalized population. The number of insured individuals in the USVI was 72,922 (69.2%), 45.9% (48,356) had private health insurance, including people with TRICARE/military, 14.7% (15,469) had public health insurance, and 8.6% (9,097) reported as having both private and public health insurance. Reports from the 2003 US Virgin Islands Health Care Insurance and Access Survey stated that nearly one- quarter (24.1%) of US Virgin Islands residents were uninsured (State Health Access Data Assistance Center [SHADAC], 2004). This is an almost 6% increase in the amount of uninsured individuals over a 7 year period. In comparison, the national estimate for uninsured persons was 16.3% in 2010, which is considerably lower than the proportion in the USVI. One factor that could have contributed to the high proportion in the VI would be the small amount of employer coverage within the territory. Since the USVI relies heavily on tour- ism, work within the territory is usually seasonal, temporary, and/or low-wage. Therefore, Virgin Islanders are less likely to be offered health insurance by their employers and would more than likely lose their bene- fits due to high employment fluctuations and layoffs (SHADAC, 2004). Variations were seen in the proportion insured amongst the islands. St. Thomas had the highest amount of group coverage (49.9%) compared to St. Croix who had a lower proportion (41.5%). Further, public coverage was significantly higher on the island of St. Croix (26.0%) compared to coverage on St. Thomas (18.5%) (SHADAC, 2009). Factors such as race and age also played a role in the insurance rates in the USVI. According to SHADAC, per- sons identifying as Hispanic had the highest uninsured rate (37.3%) followed by blacks (28.3%) and then whites (20%). Similar to the US, young adults between the ages of 18-24 years had the highest rates amongst the uninsured (53.4%) of all the other age groups in the USVI (SHADAC, 2009). The uninsured rates were the lowest for residents over the age of 65. Other factors such as income level, employment status, and employ- er firm size, also played a large role in insurance coverage. EDUCATIONAL STATUS In 2010, 30.5 % (21,598) of persons 25 years or older in the USVI had at least a high school diploma, while only 19.2 % (13,579) had a bachelor’s degree or higher. About 31% (22,022) of persons 25 and older did not have a high school diploma and 16.3 % (11,543) of the population had less than a 9th grade education. Differ- ences in educational attainment were present amongst the islands. The proportion of residents 25 years of age or older, with at least a high school diploma, was 30.2% for St. Croix, 31.2% for St. Thomas, and 25.4% on St. John. The distribution of residents that obtained a bachelor’s degree followed a similar pattern with 18.3% in St. Croix, 19.2% in St. Thomas, and 28.0% in St. John. This information is important and should be taken into account when developing prevention programs and materials that would be specific to those with less than a high school education. LANGUAGE SPOKEN According to the 2010 Census, 71.6% (70,864) of USVI residents over five years of age spoke English only. Of the remaining population over the age of five, most spoke Spanish/Spanish Creole at home. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 This number is not surprising given that persons of Hispanic origin represented 17.4% (18,504) of the USVI population. On St. Croix, 23% of the residents spoke Spanish or Spanish Creole at home, whereas, the pro- portion was 12.4% on St. John and 11.8% on St. Thomas. These percentages coincide with the differences re- ported in the proportion of the population of Hispanic origin on each island. The proportion of the population speaking only English at home was the greatest on the island of St. John (76.3%) and following closely behind, was St. Thomas (75.0%). French and French Creole was spoken at home by 8.6% of the population with St. Thomas having the highest percentage (10.3%) of French and French Creole spoken at home. INCOME AND POVERTY In 2009, the median household income in the USVI was $37,254. This is considerably lower than the US medi- an household income of $50,112, according to the 2010 Census. According to the USVI Bureau of Economic Research (USVI BER), about 11% of all households in the US Virgin Islands live on less than $10,000 per year, compared to the U.S. at 7%. Additionally, about half of USVI households live on less than $35,000 a year in comparison to a third of all households in the U.S. Income varied slightly by island with St. John having the highest median household income ($40,644), followed by St. Thomas ($38,232), and then St. Croix ($36,042). The data on the poverty level in the Virgin Islands paints a vivid picture of the economic situation of the terri- tory. According to USVI BER, in 2008 approximately 25% of residents of the USVI were living in poverty. This was almost twice the proportion living in poverty in the US at 13%. According to the 2010 Census, the pov- erty level in the USVI for families in 2010 was approximately 18% and the percent of individuals was 22%. In- dividual poverty level for USVI residents was 7% higher than the US poverty level in 2010. In comparison in 1999, the USVI poverty level for families was 29% and 33% for individuals, which shows that the poverty lev- els have significantly decreased within the past decade. Among the islands, these figures varied. St. John re- ported the lowest poverty level among families (11%) and individuals (15%) whereas St. Croix had the highest percentage of families (22%) and individuals (26%) below the poverty level. According to the USVI BER, factors that may have influenced the high poverty rates in the USVI include the fact that approximately 14% (6,875) of the workforce of the USVI was employed in the leisure and hospitality sector, which usually offers low paying jobs. Another 14% (6,807) of the total workforce of the USVI was em- ployed in wholesale and retail trade which can also be a low-paying employment sector. Since these areas are tourism based, reliable or sufficient income would be difficult to obtain. COUNTRY OF BIRTH According to the 2010 Census, 66.6% (70,838) of the USVI population are native Virgin Islanders. A large pro- portion (31.0%) of the residents of the USVI was born in Latin America and the other Caribbean islands. The primary Caribbean islands of birth included St. Kitts and Nevis, Dominica, Dominican Republic, and Antigua and Barbuda. According to the 2010 Census, 15.8% (16,851) of USVI residents were born in the U.S. mainland and 3.4% were born in other US island areas or Puerto Rico. About 2% of residents were born in Europe and Asia. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 IMMIGRATION From 2000 to 2010, a 9.6% (10,202) increase in the US Virgin Islands population was due to net migration. About 23.8% (25,365) of immigrants arrived in the islands before the year 2000. HEALTH PLANNING GEOGRAPHY The US Virgin Islands Department of Health (VIDOH) uses basic geographic boundaries when analyzing HIV disease or sexually transmitted disease data. For health planning purposes, gen- erally, program planning coordinators target the communities within the islands and they are usually distinguished by districts—the St. Thom- as/St. John District, and the St. Croix District. According to the US Census, for data presenta- tion purposes, the Census Bureau treats islands as the equivalent of counties in the United States. Legal subdivisions are categorized into sub districts on each of the islands. Geograph- ically, in the St. Thomas/St. John district, the Northside and Charlotte Amalie area of the is- land of St. Thomas and the most western side of the island of St. John (Cruz Bay) are the most heavily populated (5,500 to 18,481 persons). The Southside and the West End of St. Thomas, and the Central and Eastern End of St. John, are the least populated (51 to 5,499 persons). St. Croix’s most heavily populated area (5,500 to 18,481 persons) is located on the Northcentral subdistrict of the island, followed by the Southcentral and Southwestern subdistrict. The least populated areas on the island are the Northwest, Northcentral, Christiansted, and the East End subdistricts (800 to 5,499 persons). Although health planning coordinators generally target by communities, the following table shows each island and its sub districts that the US Census Bureau uses for distinguishing geographic boundaries on each island. St. Croix St. Thomas St. John Sub districts Sub districts Sub dis- tricts Anna’s Hope Village Charlotte Amalie Central Christiansted East End Coral Bay East End Northside Cruz Bay Fredericksted Southside East End Northcentral Tutu Northwest Water Island Sion Farm West End Southcentral Southwest U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 HIV INFECTION OVERVIEW QUESTION 1.2 What is the scope of HIV burden in the U S Virgin Islands? With a population of only 106,405 residents, the US Virgin Islands represents only 0.03% of the total popula- tion of the United States (319 million). According to the CDC 2014 HIV Surveillance Report, the USVI com- prised only 0.05% of all 2014 HIV infection diagnoses in the country. The territory ranked 5th among the 50 states, the District of Columbia, and other US dependent areas in the rate of new HIV diagnoses. On average, there were 25 persons with HIV infection diagnosed each year in the USVI for the past 5 years. According to the CDC, in the USVI, for every 100,000 persons in the population, 27.4 were diagnosed with HIV infection in 2014. Based on USVI surveillance data, there were 27 diagnoses of HIV infection in 2014. Of the 27 diagno- ses, 17 cases were classified as HIV (not AIDS) and 10 were classified as AIDS (stage 3) by the end of 2014. HIV Infection Prevalence Due to advances in medicine, more people are living longer with HIV infection. As of December 31, 2014, there were 643 people known to be living with HIV infection in the USVI, with a prevalence rate of 617.3 per 100,000 population. Over half (55.1%) of this population has progressed to the AIDS (stage 3). About one in 160 USVI residents were known to be living with HIV infection at the end of 2014. The majority of those living with the disease were male (57.4%), black (58.9%), and 35 years of age or older (87.2%). Persons with HIV infection attributed to heterosexual contact represented the largest percentage of persons living with HIV infection (34.4%). U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 HIV Infection Diagnoses Cumulatively, there have been 1,112 persons with HIV infection diagnosed through 2014 and reported to the Virgin Islands Department of Health (VIDOH), whose residence at the time of the diagnosis was the USVI. Of these cases, 767 (69.0 %) were classified as AIDS (stage 3) at the end of 2014 and 345 (31.0%) were classified as HIV (not AIDS). By Sex Men accounted for 59.8 % of the new HIV infection diagnoses from 2010 to 2014. By Transmission Category Among females diagnosed from 2010 to 2014, 41.2% of diagnoses were attributed to heterosexual contact, while only 19.7% were attributed to heterosexual contact for males. Among males 30.3% of new diagnoses were attributed to male to male sexual contact. It should be noted that 48.7% of males and 54.9% of females diagnosed with HIV infection had no identified risk reported, so interpreting trends by transmission category 19 17 7 14 19 11 10 8 14 8 0 5 10 15 20 2010 2011 2012 2013 2014 No. of Cases Year Diagnoses of HIV infection, by year of diagnosis and sex, 2010 to 2014 - Virgin Islands Male Female U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 continues to be difficult. Please note that the no identified risk category includes persons who have reported sexual contact with a person of the opposite gender, but did not report whether their sexual partner was known to have, or to be at high risk for HIV infection. Efforts have been made to improve identification of transmission category in recent years. By Race/Ethnicity Blacks represented the largest proportion of the Virgin Islands population (66.1%). Blacks also represented the greatest proportion of new HIV infection diagnoses from 2010 to 2014 (52.8%) and the greatest propor- tion of persons living with HIV infection at the end of 2014 (58.9%). The burden of HIV infection continues to have a disproportionate impact on certain populations. It should be noted that the Hispanic population only made up 17.4% of the USVI population in 2010. However, they accounted for 30.3% of persons living with HIV infection at the end of 2014. 23, 30.3% 1, 1.3% 15, 19.7% 37, 48.7% Diagnoses of HIV infection, by transmission category, 2010 to 2014 - Virgin Islands Male to Male Sexual Contact (MSM) Injection Drug Use (IDU) Heterosexual contact No identified risk FEMALES MALES 2, 3.9% 21, 41.2% 28, 54.9% 66.1% 59.3% 58.9% 13.5% 11.1% 8.6% 17.4% 14.8% 30.3% 3.0% 14.8% 2.2% 0% 20% 40% 60% 80% 100% VI population, 2010 New HIV Infection Diagnoses, 2014 Persons Living with HIV Infection, 2014 % of Cases Racial disparities, HIV infection, 2014 - Virgin Islands Black White Hispanic* Other *Hispanic can be of any race 67, 52.8% 10, 7.9% 45, 35.4% 5, 3.9% Diagnoses of HIV infection, by race/ethnicity, 2010 to 2014 - Virgin Islands Black White Hispanic* Other *Hispanic can be of any race U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 By Age at Diagnosis Of new HIV infection diagnoses between 2010 and 2014, the greatest proportions were between 35–44 (26.0%) and 45–54 (24.4%) years of age at diagnosis. The majority of new HIV infection diagnoses between 2010 and 2014 were among persons 35 years of age or older (70.9%). In comparison, in the United States and dependent areas, only 46.1% of new HIV infection diagnoses in 2014 were among persons 35 years of age or older. Of the cumulative HIV infection diagnoses through 2014, among females the greatest proportion were 25–34 of age at diagnosis (32.5%), followed by those 35–44 years of age (28.6%). Among males the greatest proportion were 35–44 years of age (31.8%) followed by those 25–34 years of age (27.0%). 0 2 4 6 8 10 12 2010 2011 2012 2013 2014 No. of Cases Year Diagnoses of HIV infection, by year of diagnosis and age at diagnosis, 2010 to 2014 - Virgin Islands 13-24 25-34 35-44 45-54 >54 2% 8% 27% 32% 21% 11% <1% 3% 13% 32% 29% 14% 9% <1% 0% 10% 20% 30% 40% <13 years 13-24 25-34 35-44 45-54 >54 Unknown % of Cases Age group Diagnoses of HIV infection, by age at diagnosis and sex, cumulative through 2014 - Virgin Islands Male Female U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 By Country of Birth The burden of HIV infection has a disproportionate impact by coun- try of birth. Persons born in the Virgin Islands make up 66.6% of the USVI population. However, of persons with new HIV infection diag- noses between 2010–2014, Virgin Islands-born residents only ac- counted for 24.4% of diagnoses. Overall, the majority of persons with newly diagnosed HIV infection between 2010–2014 and a known country of birth were born outside of the US Virgin Islands (70.8%). Persons born in Haiti and the Dominican Republic account for 5.7% of the USVI population. However, persons born in these countries accounted for 21.3% of HIV infec- tion diagnoses between 2010–2014. For every 10 US Virgin Islanders di- agnosed with HIV infection, approxi- mately: 7 are men 6 are black 3 are aged 35-44 at diagnosis 31, 24.4% 28, 22.0% 27, 21.3% 14, 11.0% 27, 21.3% Diagnoses of HIV infection, by country of birth, 2010 to 2014 - Virgin Islands Virgin Islands United States and Puerto Rico Haiti and Dominican Republic Other Caribbean Islands Other/Unknown Geography While HIV has affected each island in the US Virgin Islands, some islands have been disproportionately im- pacted by HIV infection. About 47.6% of the population resides in the St. Croix district. However, only 40.7% of cumulative HIV infection cases were diagnosed in St. Croix. At the end of 2014, 37.6% of persons living with HIV infection resided on St. Croix at time of diagnosis. In contrast the St. Thomas/St. John district is home to 52.4% of the Virgin Islands population. However, 58.5% of cumulative HIV infection cases were diag- nosed in the St. Thomas/St. John district. At the end of 2014, 61.9% of persons living with HIV resided in the St. Thomas/St. John district at the time of diagnosis. Among people newly diagnosed from 2010 to 2014, 49.6% resided in the St. Croix district and 50.4% resided in the St. Thomas/St. John district at time of diagno- sis. Of persons living with HIV infection, nearly equal proportions of persons diagnosed in the St. Thomas/St. John district and St. Croix district were male (57.5% and 57.4% respectively); a greater proportion of persons diagnosed in the St. Thomas/St. John district were greater than 34 years of age (89.2%) and black (68.1%) compared to the St. Croix district (83.9% and 43.8%). In the St. Croix district, Hispanics accounted for 49.2% of persons living with HIV infection compared to only 18.8% in the St. Thomas/St. John district. Among per- sons with newly diagnosed HIV infection between 2010 and 2014 in the St. Croix district, 66.7% were male, 66.7% were greater than 34 years of age, and 42.9% were Hispanic. In contrast, among persons with newly U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 diagnosed HIV infection between 2010 and 2014 in the St. Thomas/St. John district, 53.1% were male, 75.0% were greater than 34 years of age, and 28.1% were Hispanic. Diagnoses for HIV infection, by district, 2010 to 2014- Virgin Islands St. Croix St. Thomas/St. John Male 53.1% 66.7% >34 years 75.0% 66.7% Hispanic 28.1% 42.9% St. Croix St. Thomas/St. John Male 57.5% 57.4% >34 years 89.2% 83.9% Hispanic 18.8% 49.2% Persons living with diagnosed HIV infection, by district, 2014 - Virgin Islands 12 12 10 18 11 18 15 5 10 16 0 5 10 15 20 2010 2011 2012 2013 2014 No. of Cases Year Diagnoses of HIV infection, by year of diagnosis and district of residence at HIV infection diagnosis, 2010 to 2014 - Virgin Islands St. Croix St. Thomas/St. John HIV/AIDS Mortality Mortality among persons with diagnosed HIV infection was low in the Virgin Islands. The cumulative number of deaths among persons classified as HIV (not AIDS) was 56 and 413 for persons classified as AIDS (stage 3). The average number of deaths per year among persons with diagnosed HIV infection from 2010 to 2014 was 10.2. Deaths ranged from the highest value of 14 in 2012 to the lowest value of 9 in 2010, 2011, and 2013. Among the 51 people with HIV infection who died between 2010 and 2014, 66.7% were male and 68.6% were black. There were some shifts from the cumulative deaths by district at diagnosis and age at death. A greater proportion of deaths between 2010 and 2014 were among persons residing in St. Croix at time of di- agnosis (54.9%) compared to cumulative deaths (45.0%). Persons over 54 years of age accounted for 49.0% of deaths between 2010 and 2014. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 This is a shift from the cumulative deaths where only 19% of deaths were among persons over 54 years of age. This is an indication that persons are living longer with HIV infection. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 QUESTION 1.3 What are the indicators of risk for HIV infection in the U S Virgin Islands? Indicators of risk for HIV infection are conditions or factors that strongly increase the likelihood of a person’s exposure to HIV. Certain behaviors and factors can increase the risk of contracting or transmitting HIV, di- rectly and indirectly. Direct measures provide information about risk behaviors that are directly associated with HIV transmission. Indirect measures do not directly describe HIV risk behaviors. Sexual behaviors are the leading factor driving the HIV epidemic. Most HIV infections are spread through sexual contact. The shar- ing of needles is another direct mode of HIV transmission. Some behaviors that increase the risk for HIV in the US Virgin Islands include: Þ Unprotected Sex - unprotected vaginal, anal, or oral sex with a person who is infected with HIV is consid- ered high risk behaviour for contracting or transmitting HIV. Men who have sex with men are most vul- nerable due to the tearing of tissue during anal sex which allows HIV to more easily enter the body. Þ Multiple Sexual Partners—Having more than one partner increases the chance that a person may come into contact with a partner who has a different HIV status. Þ Sharing Needles– Because HIV is concentrated in blood more so than other bodily fluids, the risk for con- tracting or transmitting HIV is high if an HIV– negative person uses needles after someone with HIV. Þ Sexually Transmitted Diseases—Many sexually transmitted infections (STDs) produce open sores on the genitals. These sores act as doorways for HIV to enter the body. Persons with STDs, such as chlamydia, gonorrhoea, syphilis, and herpes are more likely to contract or transmit HIV to others. Þ Alcohol and Drugs —While not a direct factor for HIV infection, the overuse of alcohol and drugs increases the risk of contracting or transmitting HIV because these substances impair a person's judgement causing them to engage in behaviors such as unprotected sex with unknown individuals. Þ HIV Positive Mothers—infants born to HIV infected mothers are at risk for contracting HIV infection from their mothers during pregnancy, during the birth process and during breastfeeding. Þ HIV Viral Load—Having a high viral load greatly increases the risk of transmitting HIV to an uninfected per- son. Persons with an undetectable viral load are significantly less likely to transmit their infection to oth- ers. Most states and territories use the Behavioral Risk Factor Surveillance System (BRFSS) to collect prevalence data among adult US residents regarding their risk behaviors and preventive health practices that can affect their health status. The most recent BRFSS survey for the Virgin Islands was conducted in 2011. Other recom- mended data sources such as the Youth Risk Behavioral Survey (YRBS), Medical Monitoring Project (MMP) and National HIV Behavioral Surveillance System (NHBS) are not available in the Virgin Islands. Due to availa- ble data sources, risk behavior will be explored using STD Surveillance data, late diagnoses and viral suppres- sion. Persons who are diagnosed late and persons who are not virally suppressed are more likely to transmit HIV unknowingly. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Sexually Transmitted Diseases (STDs) Sexually Transmitted Diseases (STDs) are influential factors in the transmission of HIV disease as they in- crease susceptibility and infectiousness. Individuals infected with STDs such as herpes, syphilis, chlamydia, gonorrhea, and trichomoniasis are at least 2 to 5 times more likely to acquire HIV than uninfected persons. Individuals that are HIV infected and have other STDs are more likely to transmit HIV to others. The data in this section explore reported cases of chlamydia and gonorrhea in the US Virgin Islands from 2010 to 2014. Syphilis data are not displayed in this section because less than five (5) cases were reported per year. Adequate analysis of the impact of this disease cannot be performed. In the Virgin Islands, STDs represent the highest burden for reportable diseases. Cases of chlamydia increased from 587 in 2010 to 791 in 2014 with some fluctuation be- tween those years. The larg- est increase was between 2010 and 2011, (587 to 820 cases) an increase of 233 cas- es. In comparison the number of reported gonorrhea cases is significantly lower than chlamydia in the Virgin Is- lands. Between 2010 and 2014, the number of gonorrhea cases reported ranged from 58 to 139. In 2014, 74.5% of chlamydia cases and 68.2% of gonorrhea cases reported were among females. Females are more likely to be screened for STDs than males which may partially explain the disproportionate number of chlamydia and gonorrhea cases reported among females. Of the 590 chlamydia cases reported among fe- males, 50.3% were between 20-29 years old and 30.7% were between 15 –19 years old. Among females, those 15-19 and 20-29 also repre- sented the largest number of re- ported gonorrhea cases. These age groups accounted for 44.8% and 36.2% of cases among females, respectively. 587 820 801 775 791 136 139 136 58 85 0 100 200 300 400 500 600 700 800 900 2010 2011 2012 2013 2014 NUMBER OF CASES CHLAMYDIA GONORRHEA Chlamydia and Gonorrhea cases, 2010 to 2014 - Virgin Islands U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 There are more reported chlamydia and gonor- rhea cases among persons less than 30 years of age compared to persons more than 30 years of age. This may be attributed to the differences in the frequency for screening for chlamydia and gonorrhea by age. Blacks less than 30 years old account for 64.9% percent of all chlamydia cases and 72.9% of all gonorrhea cases reported in 2014. Late Diagnosis A late diagnosis is defined as an individual whose disease has already progressed to AIDS (stage 3) at the time of diagnosis or someone whose AIDS (stage 3) diagnosis was within 12 months of the initial HIV infection di- agnosis. Late diagnosis is associated with a number of negative consequences for the individual and the broader public. Late diagnosis increases the risk of transmitting the virus to others. Persons with a late diag- nosis are unaware of their HIV status and unable to reduce risk behaviors or initiate antiretroviral therapy to lower their HIV viral load. In the Virgin Islands, from 2009 to 2013, there were 137 persons diagnosed with HIV infection. Of those diag- noses, 56 (40.9%) were diagnosed late. Among men diagnosed from 2009 to 2013, 51.9% were late diagno- ses. Only 25.9% of females were late diagnoses. The percentage of late diagnoses generally increased as age at diagnosis increased. By race/ethnicity, whites had the greatest percentage of late diagnoses (50.0%). How- ever, the number of new diagnoses among whites was low (10 cases). Of the blacks diagnosed between 2009 and 2013, 45.1% had a late diagnosis. In comparison, only 35.2% of Hispanics were diagnosed late. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Viral Suppression Viral suppression is defined as less than 200 copies/mL of virus in a person’s bloodstream. Persons who achieve viral suppression can improve their health outcomes and reduce the risk of transmitting HIV to oth- ers. If the greater proportion of the HIV population is virally suppressed, the number of new HIV infections will be reduced. For viral suppression data presented in this section, persons whose most recent HIV viral load test in 2014 was less than 200 copies/mL were considered virally suppressed. Among persons living with HIV infection in the Virgin Islands, 28.8% were virally suppressed. Viral suppression was lowest among per- sons 25 to 34 years of age (15.4%) and among whites (17.3%). Efforts to improve viral suppression should fo- cus on these groups. Further discussion regarding viral suppression can be found in Question 2.1. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 SECTION 2 Ryan White HIV/AIDS Program QUESTION 2.1 What is the impact of the care and treatment services of the Ryan White HIV/AIDS Programs on people living with HIV? The Ryan White HIV/AIDS Program is a federally funded program designed to assist individuals living with HIV infection who lack the financial and /or health coverage resources to treat their HIV infection. The United States Department of Health and Human Services (US DHHS), Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB) administers the program at the federal level. The program has five parts: • Part A: funds eligible metropolitan areas and Transitional Grant Areas that are severely affected by the HIV epidemic; • Part B: funds the states and territories to improve the quality, availability and organization of HIV health care and support services. All 50 states, the District of Columbia, Puerto Rico, Guam, the US Virgin Islands, and the 5 US Pacific Territories are eligible for this funding. Part B also includes funding for the AIDS Drug As- sistance Program (ADAP); • Part C: funds local community-based organizations such as clinics to support primary care for people living with HIV/AIDS.; • Part D: funds individual organizations to provide family-centered care for women, infants, children and youth with HIV infection; and • Part F: funds support research, technical assistance and access-to-care programs including special projects of National significance program, AIDS Education and Training Centers Program (AETC), Dental Programs, and Minority AIDS Initiative. The U.S. Virgin Islands receives Ryan White assistance through Parts B and C. These programs are adminis- tered locally by The U.S. Virgin Island’s Department of Health, Communicable Disease Division, The Frederik- sted Health Center and St. Thomas East End Medical Center. The HIV unit has interagency agreements with agencies to deliver HIV/AIDS Non-ADAP Core and Support services to Part B eligible individuals throughout the Territory. Approximately a quarter (25.6%) of the reported persons living with HIV/AIDS (PLWHA) in the USVI are ac- cessing services through Part B of the Ryan White HIV/AIDS Program (RWHAP). Slightly less than 15% of PLWHA are accessing services through the Part C RWHAP. Some clients are receiving services through both the Parts B and C programs. The characteristics of persons who receive care through Ryan White’s Part B and C correspond with the over- all HIV population reported to the Virgin Islands HIV Surveillance program. The greatest proportion of clients in the RWHAP B and C programs and overall HIV population are males (53.9%, 49.5% and 57.4%, respective- ly). The distribution of RWHAP Part B and C clients by age is similar to the distribution among U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 the overall HIV population. There are some differences by race/ethnicity. A greater proportion of Ryan White Part C clients are Hispanic (54.8%) compared to Ryan White Part B clients (30.3%) and the overall HIV popula- tion (30.3%). Differences in transmission category among both RWHAP Part B and C in comparison to the overall HIV population are evident among infections attributed to heterosexual contact. In RWHAP Part B program, heterosexual clients account for 72.7%, and 75.0% in Part C, while heterosexual clients account for 34.4% in the overall HIV population. This may be attributed to the differences in the classification of hetero- sexual contact between the RWHAP and HIV surveillance program. As a result of the different definitions for classifying heterosexual contact, 35.8% of the overall HIV population based on data from the HIV surveillance program did not have an identified transmission category. For the HIV surveillance program, the NDI/ Unknown category may include persons who have reported sexual contact with a person of the opposite gender, but did not report whether their sexual partner was known to have, or to be at high risk for HIV in- fection. Caution should be taken when comparing data by transmission category between the RWHAP and the HIV surveillance program. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Characteristics No. % No. % No. % Male 89 53.9% 46 49.5% 369 57.4% Female 76 46.1% 47 50.5% 274 42.6% Total 165 100.0% 93 100.0% 643 100.0% <13 1 0.6% 3 3.2% 2 0.3% 13 - 24 0 0.0% 7 7.5% 15 2.3% 25-44 58 35.2% 33 35.5% 208 32.3% 25 - 34 N/A N/A 11 11.8% 63 9.8% 35 - 44 N/A N/A 22 23.7% 145 22.6% 45-64 91 55.2% N/A N/A 352 54.7% 45 - 54 N/A N/A 29 31.2% 205 31.9% >64 15 9.1% N/A N/A 64 10.0% >54 N/A N/A 21 22.6% 211 32.8% Unknown 0 0.0% 0 0.0% 2 0.3% Total 165 100.0% 93 100.0% 643 100.0% Black 102 61.8% 38 40.9% 379 58.9% Hispanic* 50 30.3% 51 54.8% 195 30.3% White 12 7.3% 4 4.3% 55 8.6% Other 1 0.6% 0 0.0% 14 2.2% Total 165 100.0% 93 100.0% 643 100.0% Male to Male sexual contact (MSM) 36 21.8% 12 12.2% 120 18.7% Injection Drug Use (IDU) 9 5.5% 8 8.6% 47 7.3% MSM and IDU 0 0.0% 2 2.1% 12 1.9% Heterosexual contactc 120 72.7% 70 75.0% 221 34.4% Perinatal exposure 0 0.0% 2 2.1% 13 2.0% NIR / Unknown 0 0.0% 0 0.0% 230 35.8% Total 165 100.0% 93 100.0% 643 100.0% Age at the End of 2014 (yr) Race/Ethnicity Transmission Category aUnique number of clients within each part of the Ryan White program. If the client is enrolled in both the Part B and Part C programs, the client will be counted twice, once under Part B and once under Part C. bIncludes all persons with diagnosed HIV infection, regardless of status at diagnosis or current status, who were residents of the Virgin Islands at the time of diagnosis and were presumed to be alive at the end of 2014. Based on information reported to the Virgin Islands Department of Health's HIV surveillance program. *Hispanics can be of any race. cThe definition for heterosexual contact is different between the Ryan White HIV program and the HIV surveillance program. For the Ryan White program, heterosexual contact is defined as persons who have ever reported sexual contact with a person of the opposite gender. For the HIV surveillance program, heterosexual contact is defined as persons who have ever had heterosexual contact with a person known to have, or to be at high risk for, HIV infection (e.g., an injection drug user). Source: Virgin Islands Ryan White CareWare system and eHARS Characteristics of persons enrolled in the Ryan White Part B Program, persons enrolled in the Ryan White Part C Program, and persons living with diagnosed HIV infection, 2014 - Virgin Islands Ryan White Part B Program Clientsa (N=165) Ryan White Part C Program Clientsa (N=93) Persons Living with Diagnosed HIV Infectionb (N = 643) Sex U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 The Ryan White HIV/AIDS Program in the Virgin Islands in conjunction with the Health Resources and Services Administration (HRSA) is required to make an analysis of individuals living with HIV who are not receiving HIV primary medical care. It should be noted that laboratory reporting to the HIV surveillance office may not be complete for persons who sought care outside the USVI. It is also important to note that the data only includes persons diagnosed with HIV infection in the USVI who are still presumed to be living, regardless of their current residence. Since there is no mechanism implemented that would be able to track patients that leave the territory, the data also does not account for the current residence for those living with HIV. Due to this, the actual number of patients that are not in care in the USVI could be higher or lower, depending on the migration patterns of these patients. Continuum of Care 100.0% 92.6% 38.2% 28.8% 612 25 234 176 0% 20% 40% 60% 80% 100% Diagnosed with HIV Infection Linked to Care in 2014 (30 days) In Care (>=1 care visit) Virally Suppressed % Care Indicators HIV continuum of care, 2014 - Virgin Islands In the USVI, patients considered as “in care” would indicate any patient that had a CD4 count or viral load test within the last 12 months. Those patients living with the disease, with no laboratory results on CD4 counts or viral loads, reported to the HIV surveillance program within the last 12 months, were classified as “not in care”. The National HIV/AIDS Strategy (NHAS) has a goal by 2020 to reduce new infections and to increase access to care and improve health outcomes for people living with HIV disease. One of their indicators of progress is to increase the percentage of newly diagnosed persons linked to HIV medical care within one month of their HIV diagnosis to at least 85 percent. In 2014, of the 27 persons diagnosed with HIV infection, 92.6% (25) re- ceived care within 1 month of diagnosis, 92.6% (25) received care within 3 months of diagnosis, 96.3% (26) within 6 months, and 100% (27) within 12 months. The US Virgin Islands met this NHAS goal. As of December 2014, there were a total of 612 persons living with HIV infection in the USVI. This only U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 includes people who were 13 years of age and older and were diagnosed by December 2013. Of these cases, only 234 persons had 1 or more care visits and were considered to be “in care” through December 2014. That indicates that only 38.2% of the persons living with HIV infection received care in 2014. Another of the NHAS indicators of progress is to achieve 80% viral suppression among persons living with HIV infection. As of December 2014 in the USVI, only 28.8% of persons living with HIV infection were virally sup- pressed. This is more than 50% below the national viral suppression goal. Ryan White Part C Continuum of Care No. % Number of Ryan White Clients Enrolled, 2014a 93 100.0% Retained in Care, 2014b 75 80.6% Antiretroviral Therapy, 2014c 80 86.0% Virally Suppressedd 52 55.9% Ryan White Part C Program aUnique number of clients within each part of the Ryan White program. If the client is enrolled in both the Part B and Part C programs, the client will be counted twice, once under Part B and once under Part C. b At least one visit to a medical care provider in each six month period in 2014. c Client taking antiretroviral therapy in 2014 based on review by medical case manager. d Persons who had a viral load test result of less than 200 copies/ml. Source: Virgin Islands Ryan White CareWare system HIV care continuum, Ryan White Part C Program clients, 2014 - Virgin Islands Among clients receiving care through the Ryan White Part C program in 2014, 80.6% were retained in care. 55.9% of Part C clients were virally suppressed in 2014. In comparison to the NHAS goals, the Ryan White Part C program is about 25% below the national viral suppression goal. Comparisons of the care continuum should not be made between the Ryan White program and the overall HIV population. The care continuum of the overall population is based on residence at diagnosis while the care continuum of the Ryan White pro- gram is based on persons enrolled in the program regardless of residence at diagnosis. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Ryan White Part C Service Utilization The Ryan White Part C program assessment of services in the Virgin Islands includes primary medical care, case management, and home or community-based care. For primary medical care, clients visited their pro- viders 11 times per year on average, which is higher than HRSA’s recommendation to see providers once eve- ry six months. This is an indication that clients are engaged in their medical care. On average, clients saw their case managers 8 times per year. In comparison to primary medical care, the average number of home or community-based care visits averaged 48 for 2014. Ryan White Part C Program Average number of visits per client 11 Median number of visits per client 16 Range of visits per client 8 Average number of visits per client 8 Median number of visits per client 18 Range of visits per client 15 Average number of visits per client 48 Median number of visits per client 33 Range of visits per client 24 Ryan White program services visits by service category, Ryan White Part C program clients, 2014 - Virgin Islands Primary medical care Medical case management Home/community-based care (HCBC) Source: Virgin Islands Ryan White CareWare system U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 QUESTION 2.2 What are some things to keep in mind as a Ryan White HIV/AIDS Program grantee prepares the epidemiologic profile document for HRSA’s HIV/AIDS Bureau? Unmet Need The Health Resources and Services Administration’s (HRSA) Ryan White HIV/AIDS Program requires an analy- sis of individuals living with HIV infection who are not receiving HIV primary medical care. In the Virgin Is- lands, the calculation of unmet need is limited to people living with HIV infection that were residents of the US Virgin Islands at the time of diagnosis. This may lead to an overestimation of unmet need as persons may no longer reside or receive care in the Virgin Islands. The Virgin Islands uses residence at diagnosis as op- posed to most recently known address since there are insufficient resources to track persons with HIV com- ing into and out of the territory. Among the people living with HIV infection, those without evidence of labor- atory test result in 2014 (CD4, viral load and genotype tests) were considered to have an unmet need or to be out of care. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Approximately 60% of persons living with HIV infection and aware of their HIV status are estimated to have an unmet need for medical care. The 2014 unmet need table is calculated in accordance to the HRSA’s frame- work and guidance. Among the total 643 persons living with HIV infection in the Virgin Islands in 2014, 384 had no evidence of HIV primary medical care, including viral load, CD4 test or genotype testing in 2014. For persons living with AIDS (stage 3), the percentage with unmet need (53.9%) was lower than persons living HIV (not AIDS) (66.8%). Demographic characteristics of persons with an unmet need living with HIV infection indicates there are a greater percentage of individuals that are aware of their HIV infection and are not receiving medical care in the St. Thomas/St. John district (63.3%) than in St. Croix (53.7%). The percentage of persons with an unmet need by sex is almost equal in the St. Croix district. But in the St. Thomas/St. John district, 67.2% of males have an unmet need in comparison to 58.0% of females. The percent of whites in St. Croix (66.7%) and St. Thomas/St. John (76.7%) have a higher unmet need. However, this group represents a small proportion of cases (12 and 43, respectively). Among the transmission categories, in St. Croix MSMs had a high unmet U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 need of 57.5%. Though the percentage of perinatal exposures is highest in both districts, the population size is rather small. Addressing Unmet Need For the 59.7% of the population living with HIV/AIDS that are estimated to have unmet need in the Virgin Is- lands, there are many unanswered questions regarding why they are not receiving HIV primary medical care. Assessments need to be conducted to determine these barriers to care. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Appendix U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Table 2 continued on the next page. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Table 3 continued on the next page. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Table 4 continued on the next page. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Table 5 continued on the next page. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Table 14 continued on the next page. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Table 15 continued on the next page. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Table 17 continued on the next page. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Table 18 continued on the next page. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Table 22 continued on the next page. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Table 23 continued on the next page. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Glossary Adult/Adolescent – Persons that are 13 years of age or older at the age of diagnosis. AIDS (Acquired Immune Deficiency Syndrome) – A result of Human Immunodeficiency Virus (HIV) infection, which disables the immune system from effectively fighting numerous opportunistic infections and cancers. Case – A condition, such as HIV or AIDS according to a standard definition (ex. HIV Case) Cumulative Cases – The total number of cases of a disease reported or diagnosed during a specified time. Diagnosed – The date on which laboratory test confirmed a disease or a physician having determined or analyzed a patient's condi- tion by evaluating signs and symptoms through diagnostic analysis. Epidemic – A disease that spreads rapidly through a defined demographic segment than would normally be expected. Epidemiology – The study of incidence and distribution and control of a disease in a population. HIV (Human Immunodeficiency Virus) – The retrovirus that causes AIDS by infecting the T-helper cells. HIV Surveillance – The continuous, systematic collection, analysis, and interpretation of HIV/AIDS data. IDU (Injection Drug Use) – A risk factor to describe individuals that use syringes, needles, or cookers to Inject illicit drugs used for producing euphoria. Incidence – The total number or rate of new cases of a disease over a period of time. Incidence rate – The total number of new cases in a specific area during a specific time period among the population at risk in the same area and time period. MSM (male to male sexual contact) – A risk factor to describe male-to-male sexual contact which includes penis-to-mouth, penis- to-anus, or mouth-to-anus. It does not include mouth-to-mouth contact. Gay, bisexual, and other men who have sex with men fall within this category. NIR (No identified risk) –Cases in which risk information cannot be identified or confirmed. Pediatric – Persons that are less than 13 years of age at the time of diagnosis. Perinatal Exposure – A risk factor that describes the possible spread of HIV/AIDS from a mother to her baby that can occur dur- ing pregnancy, labor, delivery or breastfeeding. Prevalence – The total number of persons living with HIV or AIDS in a population over a period of time. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 Prevalence rate – The percentage of the population living with HIV. Rate – The frequency of a disease compared to the number of persons at risk for the disease. Reported – The date on which an adult or pediatric HIV/AIDS case report form is entered into the HIV/AIDS reporting database. Risk factor – individual routes of HIV exposure/transmission: MSM, IDU, heterosexual contact, blood transfusion, Perinatal expo- sure, etc. Seroconvert – the development of detectable specific antibodies to microorganisms in the blood serum as a result of infection or immunization. Serorevert – the change in serostatus from positive to negative. Seroreversion occurs in infants whose antibody status changes once they have lost maternally transmitted antibodies. Trend – A long-term pattern in the progression of the disease. U S VIRGIN ISLANDS EPIDEMIOLOGY PROFILE FOR HIV/AIDS PREVENTION, CARE, & PLANNING 2014 References Centers for Disease Control and Prevention. HIV Surveillance Report, 2014; vol. 26. < https://www.cdc.gov/hiv/pdf/library/reports/ surveillance/cdc-hiv-surveillance-report-us.pdf> Published November 2015. Accessed February 24, 2016 U.S. Census Bureau. International Data Base. < http://go.usa.gov/vSU>j. Updated August 2016. Accessed August, 24, 2016.