As of 2019, 12,408 people who live in the District of Columbia are diagnosed with HIV. That figure — an estimated 1.8% of DC’s population — is based on case reports and laboratory data collected as part of routine monitoring of disease, also referred to as disease surveillance. However, the true burden of HIV in DC is higher than what is documented. Statistical modeling suggests that about 1,200 DC residents are living with HIV but unaware of their HIV status.
While the District continues to observe a reduction in the annual number of newly diagnosed HIV cases, the rate of decline has varied over the past decade. In 2019, 282 individuals were newly diagnosed with HIV in the District, marking a 29% decrease from the 399 newly diagnosed HIV cases documented in 2015.
Unfortunately, such declines have not been consistent across all populations, contributing to persistent demographic disparities in the risk and burden of HIV within the District. We saw a 42% decline in the number of newly diagnosed HIV cases within the white population over the past five years, compared with 24% and 37% declines over the same time period documented within the Black and Latino communities, respectively. Overall, the largest proportion of newly diagnosed HIV cases from 2015 through 2019 was Black men who have sex with men (31%), followed by Black women (21%), for a combined total of 1,766 residents. The next highest figures are white men (9%) and Latino men (9%) who have sex with men. Approximately 3% of newly diagnosed HIV cases in the District from 2015 through 2019 occurred within the transgender community — although this is most likely an underestimate, due to limitations of the data.
Slightly over 50% of all individuals living in the District diagnosed with HIV are 50 or older; however, newly diagnosed HIV cases tend to occur within younger age cohorts. From 2015 through 2019, approximately 34% of newly diagnosed HIV cases in the District occurred among those ages 20 to 29, with individuals ages 30 to 39 accounting for the second-largest proportion of newly diagnosed HIV cases (28%).
Geographically, the highest HIV burden and rates of new infection are observed in the eastern region of the District, comprising wards 5, 6, 7, and 8.
Of those diagnosed with HIV living in the District, there is evidence that approximately 80% are engaged in HIV care (reflected by their having at least one laboratory report with a CD4 or viral load measurement) in 2019, with 87% of those engaged in care having an undetectable viral load (less than 200 virus copies/mL) based on their last laboratory report during the year.
Of the 1,766 newly diagnosed HIV cases from 2015 through 2019, 88% were linked to care within 30 days of diagnosis and 60% had evidence of achieving viral suppression within 90 days of diagnosis. There is evidence of some variation among demographic groups in the level of engagement in HIV care. Even larger disparities are apparent when it comes to viral suppression among those engaged in care. Notably, 95% of white individuals living in the District diagnosed with HIV who were engaged in HIV care in 2019 had evidence of being virally suppressed based on their last documented laboratory report, compared with 72% of Black individuals and 68% of Latino individuals.
A similar disparity is also observed with regards to age. Approximately 90% of individuals living in the District diagnosed with HIV age 40 and over who have an HIV diagnoses and were engaged in HIV care in 2019 had evidence of being virally suppressed based on their last documented laboratory report, compared with 79% of individuals age 39 and younger.
While the total number of deaths among individuals diagnosed with HIV living in the District diagnosed with HIV declined slightly between 2016 and 2018 (from 314 to 277), the proportion of deaths attributable to HIV has remained relatively stable. Less than 30% of the deaths occurring from 2016 through 2018 among individuals diagnosed with HIV living in the District had HIV documented as the primary cause of death. The most prevalent documented primary causes of death among individuals living with HIV in the District are cancer, cardiovascular disease, and accidental death.
While we continue to document positive epidemiologic trends in HIV diagnosis, care engagement, viral suppression, and mortality within the District, challenges remain with regards to reducing inequities across the population in the risk and burden of infection.
Complete Epidemiology Profile: HAHSTA Annual Epidemiology & Surveillance Report 2020
First, there are fundamental social threats: structural racism, stigma, and inequity. The negative impact of racism on health is widely recognized, and ongoing systemic, structural change is needed to improve health outcomes in historically marginalized communities. Improving health and well-being in these communities is no small task — meaningful change requires respect and cultural humility while addressing ways to undo the systems that hold damaging policies in place. As part of this plan and for all future actions, DC Health acknowledges and will address the impact of structural racism on sexual health and HIV outcomes.We will begin by developing a framework for promoting social justice in our work, centering the voices and lives of Black and Latino/a/x people and creating our principles and dedicating resources to erode racism and inequity. Internally, DC Health will intentionally look at race and racism, working mindfully and fully taking into account the diversity of the populations it serves, the diversity of its workforce, and the larger context in which DC Health delivers programs and develops policies.
DC Health will:
Acknowledging structural racism and addressing it are fundamental to ensuring equity. It is equally important to assure equitable access to resources and opportunity to all people, regardless of racial, ethnic, gender, and sexual identities. DC Health has developed programs on the health of people who use drugs, sexual pleasure, and social and emotional well-being, and initiatives that address matters such as employment, fellowship, and housing. It has also aimed to not assign risk to people based on their identities, instead defining risk in terms of behavior (for example, not wearing condoms, not knowing the status of a partner) to lessen the stigma people might feel. All recent programs and efforts have aimed for diversity, equity, and inclusion of a number of populations often left at the margins, as well as to decrease the stigma placed on some of these populations.
Additional ongoing initiatives that help increase equity and reduce stigma are:
Second, there are local challenges to the District’s reaching its goal, obstacles that reflect geography as well as life priorities as expressed by residents during community engagement sessions, a series of small gatherings held with a diversity of groups throughout 2020.
One challenge to ending the HIV epidemic in the District is that DC is a small jurisdiction within a large and complex metropolitan area that includes parts of three other states. People live, work, play, and access health services irrespective of jurisdictional lines. The metropolitan area covers counties in Maryland, Virginia, and West Virginia, and the District. Two jurisdictions that also received funding through the CDC’s Ending the HIV Epidemic initiative — Montgomery County and Prince George’s County — directly border the District. Baltimore City, another funded jurisdiction, is 30 miles from Washington.
Another challenge is how HIV factors into the lives of focus populations. DC Health initiated its community engagement sessions with a simple yet multilayered question: “What’s going on in the lives of (your population)?” Subsequent questions included asking about resiliency and impacts on the population, the role of sexual health, and resources that would support overall health. Across a diversity of community members, HIV health was not among the top concerns.
The following sections present findings from a needs assessment, emerging themes from community engagement sessions, and additional strategies and activities DC is including in its updated Ending the HIV Epidemic plan.
The Washington, DC Regional Planning Commission on Health and HIV (COHAH), which serves as the Ryan White Planning Council and HIV Prevention Planning Group, completed a needs assessment in 2017 as a part of COHAH activities to regularly evaluate Ryan White services and community needs. Data from this needs assessment show that overall, people living with HIV were:
Respondents in focus groups and interviews identified mental health services, psychosocial support, and assistance with housing services in the eligible metropolitan area as important needs. When it came to linking with HIV care, the most consistently reported barriers across communities were psychosocial and emotional factors. Barriers to using and adhering to HIV care and treatment included the cost of housing, the availability of housing, and discrimination in housing, particularly in DC and Maryland.
To address some of these barriers — especially as they affect marginalized populations — DC is:
COVID-19 interrupted DC’s 2020 needs assessment, so the next comprehensive needs assessment will be conducted in 2021. There will be an emphasis on reaching people who are out of care or who recently re-engaged in care. The needs assessment will also include people who are HIV negative to better understand HIV prevention needs.
In October 2019, DC Health increased its efforts to engage communities, but it paused those activities in March 2020 to launch COVID-19 prevention measures. In May 2020, DC Health resumed its engagement activities, using virtual platforms.
Through these efforts, as of late 2020, DC Health has heard from approximately 740 community members from a diversity of communities, many who are not traditionally part of engagement efforts or meetings. While many unique experiences were shared during population-specific sessions, several themes arose across communities:
DC determined the strategies for its updated plan using a health-equity and trauma-informed framework. DC’s strategies are: testing, U=U, pre-exposure prophylaxis and post-exposure prophylaxis (PrEP and PEP), rapid antiretroviral therapy (Rapid ART), molecular surveillance, Data to Care, harm reduction, and wellness services. These strategies align with the four federal pillars — Diagnose, Treat, Prevent, and Respond — and an additional, DC-specific pillar, Engage.
Resources in the form of partnerships, funding, and new approaches will support the planning and development of programs to carry out these strategies. DC Health will ensure that programs are accessible and responsive to DC’s diverse communities and their unique intersectional needs.
DC Health continues to leverage its working partnerships across jurisdictions, including community providers and consumer and stakeholder groups and entities in government, academia, and education. Funding through the Health Resources and Services Administration (HRSA) 20-078 and the CDC PS20-2010 enables DC Health to expand access to programs, supporting the availability of innovative and effective medical, support, and prevention services, to people living with HIV and people who are HIV negative. Under HRSA-20-078, the funding will also engage people who previously were not eligible to receive Ryan White services. In addition, DC Health received a supplemental Ending the Epidemic award through the National Institutes of Health-funded District of Columbia Center for AIDS Research (DC CFAR) for planning new approaches on PrEP, molecular surveillance, and Rapid ART.
DC Health has adopted a status-neutral approach through the Regional Early Intervention Services model to create innovative and culturally appropriate services, either within specific stages or along the full continuum of HIV prevention, testing, care, and treatment. The goal is to improve access to and use of high-quality, client-centered services for individuals living in the DC eligible metropolitan area most affected by the HIV epidemic.
In addition, DC Health continues its commitment to address health inequities in communities. It will build on its work with the DMV (District of Columbia, Maryland, and Virginia) Collaborative, innovative and expanded Data to Care, and the intersection of HIV and opioid use, while recognizing the impact of COVID-19 within systems of power and privilege.
