for Health Care Providers
Chapter 2 - Veterans with HIV/AIDS
2.1 Location of Care
Nationally, 23,463 HIV infected Veterans were in VHA care in 2008. The number of HIV infected Veterans per VISN ranged from 354 (VISN 2) to 3,100 at VISN 8. One-half of the VISNs had over 1,000 HIV infected Veterans in care that year (VISNs 3 - 8, 16, 17, 21, and 22).
Figure 1. VHA VISN Map
Although the number of HIV infected Veterans in VHA care has changed little over the past several years, there has been a geographic shift in their distribution. Between 2004 and 2008, nine VISNs had an increase in the number of HIV infected patients receiving care while 12 VISNs had a decrease. The number of Veterans with HIV/AIDS fell in the Northeast and increased in the South and Southwest; VISNs 7, 9, and 17 had the largest increases in caseloads of HIV infected Veterans (149, 100, 97, respectively) and VISNs 3, 5, and 1 had the largest decreases in the numbers of HIV infected Veterans in care (-342, -94, -80, respectively).
In 2008, just over 50% of the Veteran population with HIV/AIDS received care in the South, 20% received care in the West, 17% in the Northeast, and 12% in the Midwest. This regional distribution of Veterans with HIV/AIDS in care mirrors the distribution of new U.S. AIDS cases in 2007 (Figure 2a/b).1
Figure 2a/b. Geographic Comparison of New AIDS Case Reported to Centers for Disease Control and Prevention (CDC) in 2007 and All Veterans in Care with HIV/AIDS in 2008
At least one HIV infected Veteran was seen at each of the 128 reporting local healthcare systems. HIV patient caseloads by healthcare system in 2008 ranged from 2 to almost 1,200 Veterans with about one third of healthcare systems caring for 100 to 299 HIV infected Veterans. Figure 3 depicts the percentage of the 128 VHA healthcare systems by HIV caseload. For example, 16% of healthcare systems have caseloads of less than 25 Veterans with HIV/AIDS. Ten percent of local healthcare systems had caseloads of 500 or more veterans during 2008.
Local healthcare systems with large caseloads (over 300 HIV infected Veterans) cared for over 20% of HIV infected Veterans in VHA care in 2008. Most of these systems are located in traditional epicenters of HIV/AIDS infection - generally large urban areas. Healthcare systems with HIV caseloads between 100 - 299 cared for 35% of the HIV infected VHA Veteran population and facilities with HIV caseloads less than 100 cared for about 43% of the population.
Figure 3. Percentage of VHA Healthcare Systems by HIV Caseload
During 2008, almost 5% of HIV infected Veterans in VHA care received care at more than one VISN and 12% received care at more than one healthcare system. For each VISN and local health care system, tables in the Appendix present the number of HIV infected Veterans in VHA care in 2004 and in 2008.
The majority of HIV infected Veterans in care are men (97%); nonetheless, the VHA provides care to a substantial number (over 600) of HIV infected women. Although the proportion of HIV infected Veterans in care who are male has remained stable over the past five years, as the number of women Veterans increases, the number of HIV infected women Veterans may also increase. According to CDC estimates, approximately one quarter of those infected with HIV in the US are now women.2
The majority of Veterans in VHA care for HIV/AIDS are nonwhite. The largest racial group receiving VHA care for HIV disease is Black. In 2008, Blacks comprised half of the VHA HIV infected population (50%), a substantially greater proportion than the overall Veteran population of which 11% is Black. Whites comprise 42% of the VHA HIV infected population.
Seven percent of HIV infected Veterans identified themselves as Hispanic or Latino which is only slightly higher than the six percent of the overall VHA population that is Hispanic. Less than 1% of HIV infected Veterans in VHA care are American Indian, Alaskan Native, Asian, Native Hawaiian, or Pacific Islander. Because reporting of race and of ethnicity among Veterans in care is not complete, the actual percentages may vary slightly from those reported above.
According to the Centers for Disease Control and Prevention (CDC) national reports, Blacks are disproportionately affected by HIV. CDC estimates that of the 42,318 new AIDS cases in 2007 nationwide, 51% were Black, 30% were White, 18% Hispanic, and less than 1% were Asian, American Indian, or Alaskan Native.1 These proportions are generally similar to those observed in the HIV infected Veteran population with the exception that the reported proportion of Hispanics is smaller in VHA HIV/AIDS care.
Figure 4a/b. Comparison of Race/Ethnicity for New AIDS Cases Reported to the CDC in 2007 and All Veterans with HIV/AIDS in Care in 2008.
A breakdown of the age of HIV infected Veterans in care in 2008, by decade of life, is presented in Figure 5. Most HIV infected Veterans in care are between the ages of 40 and 59 (68%). Between 2005 and 2008 the mean age of HIV infected Veterans has increased from 50 years to 52.6 years. During this time, the proportion of HIV infected Veterans under the age of 50 has decreased by about 10% and the proportion of Veterans over the age of 60 has increased by almost as much. Today, more than 1 in 5 HIV infected Veterans in VHA care are over the age of 60. During 2008, persons aged 60 or older constituted 23% of newly identified HIV infected Veterans in VHA care (includes Veterans previously known HIV positive outside of VHA and truly new HIV diagnoses made at VHA). The increase in the number of persons aged 50 years and older living with HIV/AIDS in VHA is partly due to potent antiretroviral therapy, which has made it possible for many HIV-infected persons to live longer.
Figure 5. HIV Infected Veterans in VHA Care 2008 - Age by Decade of Life
The age distribution of those with the HIV infection differs materially between the VHA population and the general US population. The proportion of HIV infected Veterans in VHA care over the age of 50 (64%) is more than double the CDC estimates for the United States HIV population (27%).3
Little is known about the impact of HIV disease on the long term management of other chronic conditions common in the elderly (and vice versa). Given its large population of older HIV patients, VHA is in the unique position to learn from about these issues.
The age distribution of HIV infected Veterans in VHA care may change in the future for two reasons. First, it may change as increasing numbers of younger Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans enter VHA care. Second, according to CDC, more infections are occurring among people under 30 than any other age group (34%), followed by persons 30-39 (31%).2 This data confirms the need for VHA to reach new generations of Veterans with HIV prevention and treatment services.
2.3 CD4+ Lymphocyte Count and HIV Viral Load Distribution
A CD4+ lymphocyte count (CD4 count) less than 200 cells/mm3 or a CD4+ lymphocyte percentage of less than 14 % indicates advanced HIV disease or AIDS. In 2008, 14.2% of Veterans in care met the definition of advanced HIV disease/AIDS with either a maximum CD4+ lymphocyte count of less than 200 cells/mm3 and/or a maximum CD4+ percentage of 14 percent. The median nadir CD4 count (the lowest CD4 count ever in VHA records) for HIV infected Veterans in care in VHA in 2008 was 193 cells/mm3, with 57% having a nadir CD4 count below 200 cell/mm3 or a nadir CD4+ lymphocyte percentage below 14%. Among Veterans receiving antiretroviral therapy at the VHA in 2008, the national rate for HIV RNA viral control (defined as a HIV viral load of < 400 copies /mL) was 83%. Across VISNs, the rate ranged between 73% and 89%.
2.4 Veterans New to VHA Care for HIV/AIDS
In 2008, 1,459 Veterans were newly added to the national HIV CCR. This group had a mean age of 50 years, slightly less than the age of the overall HIV/AIDS population in VHA care that year. The majority of newly added Veterans were male (96%); 42% were Black and 35% were White. Six percent were reported themselves to be Hispanic/Latino. These Veterans consist of newly diagnosed as well as Veterans with a historical diagnosis such as Veterans receiving HIV/AIDS care outside the VA transferring into VHA care.
The CD4 count and percentage and the HIV viral load of these Veterans at the time of their addition to the CCR provide an estimate of their clinical status upon entering VHA HIV/AIDS care. About three in ten (31%) of such Veterans with HIV/AIDS had a CD4 count less than 200 cells/mm3 or a CD4 percentage less than 14%, indicating a diagnosis of AIDS. Overall, 44% had a CD4 counts less than 350 cells/mm3, which is the threshold for initiating antiretroviral therapy. At the time of their addition to the CCR, 44% of newly added Veterans had an undetectable HIV viral load, which suggests that a large portion of such Veterans transferred their care to VHA when they were already on antiretroviral therapy.
During the mid-to-late 1990s, advances in HIV treatments slowed the progression of HIV infection to AIDS and led to dramatic decreases in deaths among persons living with AIDS. Subsequently, the trend in the estimated numbers of AIDS deaths in the United States remained stable from 2002 through 2005 then began to decrease in 2006.1
The trend in all-cause mortality rate for Veterans with HIV/AIDS in VHA care is consistent with the national trend in estimated AIDS deaths. The all-cause mortality rate was 4.4% in 2004 and 2005 but fell to 3.5% in 2008, which represents a 23% decrease relative to the 2005 rate.
- Veteran with HIV/AIDS: For all reports in this document, a veteran is considered to have HIV disease if they are confirmed into the CCR for HIV.
- In Care. A Veteran is considered in care for this report if he or she had at least one inpatient admission, an outpatient prescription fill, or one outpatient visit in the defined time period.
- Location of Care. Determined by the state for the reporting facility caring for the veteran. States were aggregated using the same method as the Centers for Disease Control and Prevention.
- Demographics. Age was calculated at the midpoint of the time period under evaluation. Race is classified using the Office of Management and Budget (OMB) categories published in the Federal Register on July 9th, 1997 and include American Indian or Alaskan Native, Asian or Pacific Islander, Black, and White. For Ethnicity, persons are classified as of Hispanic origin or not. For the race/ethnicity, Hispanic veterans (of any race) were identified first based on the veteran's ethnicity field. We then used the race field for remaining veterans to identify if they should be mapped to Black, White, and Other. The "Other" group includes "American Indian or Alaskan Native" and "Asian or Pacific Islander".
- Laboratory test information. Data for CD4+ lymphocyte counts and percentages and HIV viral load tests were identified from the VHA laboratory test package.
- Deaths. Dates of death were obtained from both Veterans Health Administration and the Veterans Benefits Administration files.
- AIDS in the United States by Geographic Distribution. Center for Disease Control and Prevention. Available at http://www.cdc.gov/hiv/resources/factsheets/geographic.htm.
- Hall HI, Song R, Rhodes P, et al. Estimation of HIV Incidence in the United States. JAMA. 2008;300:520-529. Available at http://www.ncbi.nlm.nih.gov/pubmed/18677024
- CDC. HIV/AIDS Surveillance Report, 2005. Vol. 17. Rev ed. Atlanta: U.S. Department of Health and Human Services, CDC; 2007:1-54.
- Linley L, Hall HI, An Q, et al. HIV/AIDS diagnoses among persons fifty years and older in 33 states, 2001-2005. National HIV Prevention Conference, December 2007; Atlanta. Abstract B08-1.