The black/African American population has been significantly impacted by human immunodeficiency virus (HIV) from the beginning of the epidemic to the present day. Based on data collected from the National HIV Surveillance System from 2005 - 2008, blacks/African Americans represented 43.6% of the population yet accounted for 50.3% of new HIV infections in 37 states with name-based, confidential HIV reporting [1]. Adding to the disproportionate burden of infection, blacks/African Americans’ survival following diagnosis is lower than any other race/ethnicity in the U.S. with the exception of American Indian/Alaska Natives [2]. African-born blacks represent a growing and increasingly important sub-group of the black/African American population. Studies show that African-born black immigrants are more likely than U.S.-born blacks to be infected with HIV [3-5]. Among black/African American HIV diagnoses from 2003-2004 in eight U.S. metropolitan areas, up to 50% of cases occurred in African-born individuals [3].

Past studies point to significant epidemiological and cultural differences between African-born and U.S-born blacks regarding HIV [6-8]. African-born blacks are more likely to be infected with different strains of HIV, have different cultural values concerning health and sexuality, and have lower levels of knowledge about HIV transmission and treatment availability than U.S.-born blacks [6-8]. Due to the important differences between U.S.-born and African-born blacks, some states with moderate-to-high HIV incidence and large African immigrant populations have recognized the need to distinguish between these groups when conducting epidemiological surveillance. Increasingly, states that distinguish cases based on country of birth are finding higher rates of infection among foreign-born individuals. Surveillance in Minnesota from 2002-2005 showed that African-born individuals represented approximately 20% of HIV cases in the state, but made up less than 1% of the population [9]. The highest number of HIV diagnoses in Massachusetts from 2002-2004 were among African-born persons, comprising 38% of new cases [10, 11].

As of 2009, there were approximately 6,600 African-born individuals living in Utah, making up approximately 0.25% of the population [12, 13]. Utah uses the standard CDC race classification to categorize HIV cases, including American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, White, Latino, and Multi-race. Historically, Utah’s HIV/AIDS Surveillance reports have not included analysis by country of birth. However, the 2009 Utah HIV/AIDS Surveillance Report Profile included country of birth for the first time and reported a 33% increase in HIV diagnoses in African-born persons from 2008-2009 [14]. The purpose of this study was to expand on these findings by further disaggregating HIV/AIDS surveillance data and to evaluate the prevalence of HIV/AIDS in Utah based on country of birth for both U.S. and African-born blacks. In addition, this study sought to identify differences in transmission risk factors between U.S. and African-born blacks, as well as understanding late diagnosis among these populations.

We analyzed data reported to the Utah Department of Health (UDOH) for individuals diagnosed with HIV infection (with or without AIDS) from 2000 to 2009. Confidential HIV surveillance data is collected from various sources in Utah, including reported HIV infections from private medical providers, public and private laboratories, and state and local HIV prevention programs. The information collected is entered into the National Electronic HIV/AIDS Reporting System (eHARS), for data analysis. Utah cases are defined as individuals newly diagnosed with HIV and living in Utah. All individuals reported to be living in Utah with HIV are entered into eHARS regardless of where they were diagnosed; however, those individuals with a previous diagnosis of HIV in another state were excluded in the dataset for this analysis and were not counted as Utah cases. Foreign-born individuals living in Utah at the time of diagnosis are counted as Utah cases, although infection may have occurred in their country of origin. The data collection tool for eHARS is the standard HIV/AIDS case report generated by the CDC. A limited data set was extracted from eHARS in collaboration with the UDOH. All personal identifiers were removed prior to receiving the data set. The data set contained information such as country of birth, laboratory and clinical findings, pregnancy status, and possible modes of HIV exposure.

Findings from this study suggest that current HIV/AIDS analysis and reporting practices in Utah do not fully capture the changing demographics and epidemiological trends within the state. Of significance is the finding that HIV prevalence is over six times higher among African-born blacks than U.S.-born blacks. And while U.S.-born whites continue to account for over eighty percent of new HIV cases in the state, emerging trends in the black minority population warrant closer attention. The current practice of grouping all blacks together under the category blacks/African-American fails to take into consideration that many black people living in Utah emigrated from African regions with elevated HIV prevalence and significantly different transmission patterns. This study found a high percentage of African-born males (64.7%) and females (55.6%) who were classified as NRR. The high number of African-born cases (n = 28) in the year 2000 is likely explained by changes in immigration rules that year which established a formal program for the resettlement of HIV positive refugees in the U.S. Utah was one of the first six resettlement states selected under these new rules.

This study found a high percentage of African-born males (64.7%) and females (55.6%) who were classified as NRR. The CDC-defined NRR transmission category includes individuals for whom no mode of exposure has been identified and for individuals with heterosexual exposure if the partner is not at high-risk for HIV. The CDC currently defines high risk heterosexual exposure as heterosexual contact with a partner who is HIV-infected, a man who has sex with men, injection-drug users, or recipient of clotting factor for hemophilia or other coagulation disorders [16]. Our findings mirror those of at least one other study where African-born individuals were classified as NRR almost 70% of the time [3]. The high percentage of NRR cases among African-born persons is likely explained by heterosexual exposure, especially cases among women where no other risk factors are identified. While Utah has low HIV prevalence among women, and while the majority of HIV transmission is MSM, considering a ‘Presumed Heterosexual’ exposure category may help clarify transmission risk factors among both native and immigrant populations. This approach has been adopted by a growing number of cities and states, including New York City, New Jersey, Michigan and Virginia. In addition, Utah should consider the feasibility of interviewing foreign-born HIV positive individuals to clarify transmission risk factors.

Recent findings suggest that within the black community in the U.S. there is an increasing proportion of HIV infections that are transmitted through heterosexual contact. CDC data show that 68% of black females and 70.7% of black males reported HIV infection through heterosexual contact compared to 15.2% of white females and 11.0% of white males [1]. What is unclear is the extent to which differences in transmission patterns among African-born blacks in the U.S. skew epidemiological trends when data for U.S.-born and African-born blacks are grouped together. The findings from this study reinforce the need for a data collection tool that takes into account the growing cultural and ethnic diversity within the U.S. More precise reporting will likewise help policy makers allocate culturally relevant HIV prevention and care services that more accurately reflect needs within the community. The need for state health departments to disaggregate data is one of the priorities of the National African HIV/AIDS Initiative (NAHI) from the Office of Minority Health Resource Center (OMHRC) [17]. As the demographics of Utah are changing, factors such as race, ethnicity, and language are becoming increasingly important data points to monitor as they reveal risks for health care disparities in native-born as well as foreign-born populations.

The CDC defines ‘late testers’ as individuals who are diagnosed with AIDS within 12 months following their initial HIV diagnoses [18]. In this study, over half of African-born blacks (52.27%) progressed to AIDS within the first 12 months following HIV diagnosis, in contrast to 65.63% of U.S.-born blacks. Our findings compare with trends seen in larger HIV studies, in which black/African Americans typically do not seek early testing. That both U.S.-born and African-born blacks had higher rates of late testing than whites may be partially explained by blacks having less knowledge about the availability of HIV treatment, limited access to health care, and socioeconomic factors related to poverty, all of which have been identified as barriers to early testing [19, 20]. However, the high proportion of late testers in all groups evaluated in this study is a reminder that the progression of HIV infection to AIDS often occurs subtly, and demonstrates the importance of targeted HIV testing to high-risk groups. HIV prevention education should be tailored specifically to affected populations to account for cultural and demographic differences.

This study was subject to several limitations. First, Utah has a low annual prevalence of HIV infection among blacks/African Americans, which necessitated the need to use 10 years of HIV data to obtain sufficient sample sizes for the analysis. Second, because of the low number of HIV cases in Utah, analysis by sex and transmission category resulted in large confidence intervals. A third limitation was there was substantial missing data for specific variables of interest. For example, we were unable to evaluate CD4 counts and pregnancy status at time of HIV diagnosis due to missing data. Fourth, HIV waiver status for refugees was only available in eHARS for five years of the study (2005 – 2009). Knowing HIV waiver status is important because a refugee with a waiver automatically classifies the case as being infected prior to coming to the United States.

The study findings identify African-born blacks as an emerging population for targeted HIV prevention and care efforts that reflect the cultural and linguistic diversity of the African communities in Utah. Previously, black/African Americans had not been identified as a priority population, despite being highlighted in Utah HIV epidemiological reports for having disproportionate rates of infection. Findings reveal the importance of improved reporting of transmission risk factors among African-born blacks. Data collection tools need to be evaluated and revised to accurately measure demographic and transmission risk factors across an increasingly diverse population in Utah. Understanding HIV prevalence and risk factors in different Utah subpopulations will allow for a balanced and targeted approach to prevention, improved education to promote early testing, and appropriate distribution of treatment resources.