Nebraska in 2021 saw its highest number of new diagnoses for HIV since 2010, with the biggest relative increases coming in White men and rural residents.
While the 107 new diagnoses weren’t a record — that goes to 2001, with 127 — the higher count and the shift in demographics were enough for the Nebraska Department of Health and Human Services to issue an alert to health care providers across the state.
Dr. Matthew Donahue, Nebraska’s state epidemiologist, said at least part of the reason for the uptick, according to state data, appears to be a downturn in testing for HIV during the pandemic. During that time, public health officials and health care providers focused their resources on COVID-19. In addition, some Nebraskans either avoided or missed routine screenings for a variety of conditions.
Donahue said the recent upturn in HIV diagnoses in the state and a recent increase in syphilis point to the need for Nebraskans to get back to screenings and preventive care — not just for sexually transmitted illnesses but also for diseases such as cancer and heart disease.
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Early diagnosis for many conditions can prevent bigger problems down the road. HIV, or human immunodeficiency virus, attacks the body’s immune system. If not treated, it can lead to AIDS, or acquired immunodeficiency syndrome. Treatment can reduce the virus to undetectable levels in the body. At that point, people no longer can transmit the virus.
“The overall goal, if I had one message, is to try to get people back in for preventative health care, for health care maintenance,” Donahue said. “If you don’t have a doc, you should get one.”
Donahue said his call for screening also applies to a newer health concern: monkeypox. The state had five cases as of this past week, with more likely to be reported.
People who develop a suspicious rash, he said, need to contact a health care provider, who can work with health officials to arrange testing and begin tracing close contacts. Monkeypox is spread through close contact with infected people. During the current outbreak, it appears to be spreading largely by close contact through sex.
Identifying infections that already are out there also could help the state obtain more of the vaccine that can prevent monkeypox, Donahue said. Like other states, Nebraska has greater demand for than supply of the vaccine, known as Jynneos. The federal Centers for Disease Control and Prevention allocates the shots to states based on case counts. Donahue said state health officials are in daily contact with federal officials to get as much vaccine as they can for Nebraska.
The state, he said, is prioritizing vaccine for health care professionals who might be exposed to monkeypox on the job, including lab workers, and those at highest risk of contracting the virus. Those at highest risk are primarily men who have sex with men, particularly those with multiple sexual partners and those who attend social events where sex is involved.
Donahue said health officials looked at HIV infection rates after seeing an increase in syphilis. Seventy cases were reported in the state in 2017. That number rose in 2021 to 255, an increase of 264%. Syphilis, also on the rise globally, is easily treated if caught early.
The state saw increases in HIV diagnoses among all groups. But when looking at race and ethnicity, the greatest increase was among White men. And while new diagnoses among urban residents went from 51 in 2020 to 69 in 2021, the number of new cases among rural residents nearly doubled over the same period, from 20 in 2020 to 38 in 2021.
Donahue said state health officials wanted to alert health care providers to those shifts.
“We really wanted to call that out and hammer home that we need to start talking about screening again,” Donahue said.
While he said he can only guess why the numbers are going up, data does point to a reduction in testing during the pandemic. While the agency doesn’t see all HIV testing in the state, it partners with 26 organizations on HIV education, counseling and testing. In 2019, those groups conducted 8,100 HIV tests. The number dropped to about 5,100 in 2020 and 4,100 in 2021.
The CDC recommends that everyone ages 13 to 64 get tested for HIV at least once and that those at high risk get tested yearly.
Dr. Sara Hurtado Bares, an associate professor with the University of Nebraska Medical Center’s College of Medicine, said the CDC found that HIV testing nationally decreased 50% between 2019 and 2020 because so many health departments diverted efforts to COVID and many STI clinics closed.
Locally, the Douglas County Health Department’s STI clinic was closed during much of the pandemic because staff were redeployed to help with COVID vaccination efforts.
Donahue said the increases among White men and rural residents may have occurred because reduced access to HIV screening and care hit rural areas harder than urban ones.
Hurtado Bares said she worries that increases in rural areas actually may be higher than reflected in the data. Rural areas historically haven’t been well counted because many people travel to urban areas to get tested. They may not want to get tested where they live because of the stigma attached to the diagnosis.
Another concern: Those with new HIV diagnoses from rural counties had much lower initial counts of immune cells, known as CD4+ T cells, than those newly diagnosed in urban counties, suggesting delayed diagnosis.
“We now know that we start therapy ideally well before the CD4 count declines, because we have data that doing so really improves mortality,” Hurtado Bares said.
As for monkeypox, Donahue said, health officials are finding it likely has been in the U.S. longer than they initially thought.
He said he’s hoping that barriers to testing will be reduced as more commercial laboratories come on line. Health care providers are more familiar with ordering tests through such labs than through the Nebraska Public Health Laboratory.
“I suspect there are more cases out there,” he said.
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