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BackgroundDiagnoses of HIV in the US decreased by 17% in 2020 due to COVID-related disruptions. The extent to which this decrease is attributable to changes in HIV testing versus HIV transmission is unclear. We seek to better understand this issue by analyzing the discrepancy in expected versus observed HIV diagnoses in 2020 among persons who acquired HIV between 2010-2019, as changes in diagnosis patterns in this cohort cannot be attributed to changes in transmission.MethodsWe developed three methods based on the CD4-depletion model to estimate excess missed diagnoses in 2020 among persons with HIV (PWH) infected from 2010-2019. We stratified the results by transmission group, sex assigned at birth, race/ethnicity, and region to examine differences by group and confirm the reliability of our estimates. We performed similar analyses projecting diagnoses in 2019 among PWH infected from 2010-2018 to evaluate the accuracy of our methods against surveillance data.ResultsThere were approximately 3100-3300 (approximately 18%) fewer diagnoses than expected in 2020 among PWH infected from 2010-2019. Females (at birth), heterosexuals, persons who inject drugs, and Hispanic/Latino PWH missed diagnoses at higher levels than the overall population. Validation and stratification analyses confirmed the accuracy and reliability of our estimates.ConclusionsThe substantial drop in number of previously infected PWH diagnosed in 2020, suggests that changes in testing played a substantial role in the observed decrease. Levels of missed diagnoses differed substantially across population subgroups. Increasing testing efforts and innovative strategies to reach undiagnosed PWH are needed to offset this diagnosis gap. These analyses may be used to inform future estimates of HIV transmission during the COVID-19 pandemic.

Analyzing HIV care service targets for achieving a national goal of a 25% reduction in annual HIV incidence and evaluating the use of annual HIV diagnoses to measure progress in incidence reduction.Because there are considerable interactions among HIV care services, we model the dynamics of 'combinations' of increases in HIV care continuum targets to identify those that would achieve 25% reductions in annual incidence and diagnoses.We used Progression and Transmission of HIV/AIDS 2.0, an agent-based dynamic stochastic simulation of HIV in the United States.A 25% reduction in annual incidence could be achieved by multiple alternative combinations of percentages of persons with diagnosed infection and persons with viral suppression including 85 and 68%, respectively, and 90 and 59%, respectively. The first combination corresponded to an 18% reduction in annual diagnoses, and infections being diagnosed at a median CD4 cell count of 372 cells/μl or approximately 3.8 years from time of infection. The corresponding values on the second combination are 4%, 462 cells/μl, and 2.0 years, respectively.Our analysis provides policy makers with specific targets and alternative choices to achieve the goal of a 25% reduction in HIV incidence. Reducing annual diagnoses does not equate to reducing annual incidence. Instead, progress toward reducing incidence can be measured by monitoring HIV surveillance data trends in CD4 cell count at diagnosis along with the proportion who have achieved viral suppression to determine where to focus local programmatic efforts.