HIV continues to disproportionately affect Black/African American (hereafter referred to as Black) populations in the United States (US) [1–5]. In 2021, among persons aged ≥ 13 years, Black persons had the highest number (14,522; 41%) and rate (34.8 per 100,0000 population per year) of HIV diagnoses in the United States [6]. Additionally, Black persons had a rate that was 7.9 times as high as White persons, and if Black persons had a similar rate as White persons, HIV diagnoses could have been reduced by 37 cases per 100,000 population per year [6]. These racial/ethnic disparities persist due to the effects of social determinants of health (SDOH) which drive as much as half of health outcomes, including HIV [7].

SDOH are conditions in which people are born, grow, live, work, and age and are closely linked with social, economic, and/or environmental disadvantages that adversely affect select groups of people who have systematically experienced greater obstacles to health based on their race/ethnicity group or other characteristics (e.g., religion, socioeconomic status, age, mental health, sexual orientation, gender identity, geographic location) historically linked to discrimination or exclusion [8, 9]. Owing to a history of racial discrimination and residential segregation, some Black persons in the United States reside in areas with the highest social vulnerability (i.e., areas where the potential negative health effects on communities caused by external stressors are highest) [9]. The disproportionate impact of HIV on some Black subpopulations might be due to racial segregation and discrimination which have both been found to be more prevalent in socially vulnerable areas [7]. A study by the Centers for Disease Control and Prevention (CDC) found that in 2018, more than half of Black (52.2%) adults compared to 24.4% of White adults lived in the most socially vulnerable areas at the time of HIV diagnosis [7]. The development and prioritization of interventions that address health disparities associated with SDOH are critical, particularly for persons at higher risk for HIV infection living in areas with high levels of social vulnerability.

To address health disparities, current federal health initiatives include a focus on health equity—the attainment of the highest level of health for all people [10–13]. One of the four goals of The National HIV/AIDS Strategy (NHAS) (2022–2025) includes reducing HIV-related disparities and health inequities by improving the social circumstances of individuals and communities to support equitable health outcomes [14]. A resource critical for informing NHAS planning is the US Playbook to Address SDOH released in November 2023 [15]. The Playbook highlights ongoing and new actions that federal agencies are taking to support health and align investments to finance community infrastructure, empower communities to address SDOH, and encourage coordinated use of resources and data to improve health outcomes. To reduce disparities, it is important to address SDOH which provide the contexts that shape health behaviors and health itself [9].

Measuring health disparities is essential to advancing health equity [11]. When measuring health disparities, both absolute and relative measures of disparity should be reported and considered in the assessment of progress toward health equity – as absolute disparities provide some indication of how many lives could be improved if the difference between two rates were eliminated or reduced (i.e., preventable cases) and relative disparities measures the magnitude of the disparity [16]. To advance the goals of federal initiatives, assessing trends in Black-White HIV diagnosis disparities will help identify subgroups of people disproportionately affected by health disparities. We selected White persons as the reference group for two reasons: 1) they make up the majority population, influencing numbers of HIV diagnoses more than smaller groups, and 2) their historical sociopolitical advantages likely result in better health outcomes compared to racial and ethnic minorities [17].

This study aims to identify increasing trends in HIV diagnosis disparities among subpopulations of Black and White persons to assess where substantial improvements are needed to reach federal initiative goals. A descriptive intersectional analysis framework is used to identify disparities among different Black and White subpopulations with increasing disparities [18]. HIV diagnosis numbers and rates among Black and White persons are used to assess absolute and relative disparity trends.

This analysis found that, from 2017–2021, most HIV diagnoses among Black persons decreased per year, on average, and many among White persons had little to no detectable changes. HIV diagnoses increased per year, on average, among a small number of White subpopulations and the overall Black-White disparities in HIV diagnosis rates decreased per year, on average, with the exception of relative disparities among males which showed little to no detectable change. We observed increases per year, on average, in HIV diagnoses rates among White persons aged 35–44 years, White males who inject drugs, and White females residing in the Midwest. Additionally, increases per year, on average, in Black-White relative disparities in HIV diagnosis rates were observed among persons aged 13–24 years and residing in the West.

This analysis found increases per year, on average, in HIV diagnosis among White persons aged 35–44 years. This age group is more likely than other age groups to receive an HIV diagnosis, as younger persons are less likely to be aware of their HIV infection and have low rates of HIV testing [6]. Older persons are not routinely asked about risk for HIV by healthcare providers, do not consider themselves to be at risk for HIV, or may mistake HIV symptoms for those of normal aging [21]. Greater awareness of their HIV status, higher testing rates, and higher likelihood of providers asking about risk for HIV among persons aged 35–44 years may explain the increase in HIV diagnosis for this age group, compared to other age groups where no change was observed. In addition, White persons are more likely to receive a diagnosis sooner after HIV infection [3] and reside in more privileged areas with the benefits of greater access to resources and better infrastructure that provides greater protection to residents from adverse health conditions compared to persons of other race/ethnicities in the United States [22, 23]; this may explain why the increase in HIV diagnosis among persons aged 35–44 years was observed only among White persons.

We found an increase per year, on average, in HIV diagnoses among White males with infection attributed to IDU. White males account for the largest number of persons with diagnosed HIV infection attributed to injection drug use [6]. In recent years, the opioid (including prescription and synthetic opioids) and heroin crises have led to increased numbers of persons who inject drugs, with many communities experiencing increases in nonprescription use resulting in localized HIV outbreaks [24]. Rapid HIV transmission associated with opioid use is well documented [25–28]. The high percentage of White males who inject drugs and the risk of rapid HIV transmission associated with IDU may explain the increase in HIV diagnoses among White males with HIV attributable to IDU during the period analyzed.

Our analysis found increases per year, on average, in HIV diagnoses among White females residing in the Midwest. Although regional differences are varied and complex, some possible reasons that may contribute to our findings include White females in the Midwest being more likely to live in metro fringe areas (i.e., low-population-density areas that fall within metropolitan areas) and having access to more affordable healthcare, compared to White females residing in the Northeast and West [29]. These metro fringe areas allow for persons to be more connected socially and to a larger regional economy, increasing residents’ access to a broader range of healthcare, employment opportunities, education, and other services [29]. While the Southern region has more persons living in metro fringe areas, many Southern states have not expanded Medicaid coverage, hindering access to care, utilization of health services, and the affordability of care [30]. White females in the Midwest may have increased diagnoses likely because of fewer barriers, such as living in metro fringe areas, better access to and affordable healthcare, and residing in Medicaid expansion states which may explain their increase in HIV diagnoses. White males in the Midwest experienced no change in HIV diagnoses which may be partially explained by their healthcare seeking behavior, as males tend to seek healthcare services less often than females [31].

Although no increases per year, on average, in Black-White absolute disparity trends for HIV diagnoses were found, we did observe increases in Black-White relative disparity trends among some subpopulations. Among Black and White males aged 13–24 years, the absolute disparity trend decreased per year, on average, while the relative disparity trend increased. This occurred because, although the HIV diagnosis rate declined in both groups, the rate of improvement was smaller for Black males aged 13–24 years. Persons aged 13–24 years are the least likely of any age group to be aware of their HIV infection, retained in care, or have a suppressed viral load [1, 6] demonstrating the many missed opportunities for access to the information and tools needed to make healthy decisions. Additionally, the disparity in HIV prevention strategies, like the prescription of PrEP (11% among Black persons vs 78% among White persons) [1, 32], may also contribute to the increase in the Black-White relative disparity.

Among Black and White males residing in the West, the absolute disparity trend did not change, per year, on average, while the relative disparity trend increased. This may have occurred because, while the HIV diagnosis rate significantly declined among White males residing in the West, the decrease of a similar magnitude among Black males was not significant, in part due to the relatively higher rates. Thus, the rate of improvement was smaller for Black males residing in the West and only an increase in relative disparity was observed. Several states in the West are ranked among the highest for uptake of PrEP relative to their PrEP needs [33]. Additionally, previous research has shown disparities in the uptake of PrEP between Black and White males [34]. The high uptake of PrEP in the West may exacerbate the disparities that already exist and may explain the increase in the Black-White relative disparity among males residing in the West.

Achieving national goals and ending the HIV epidemic in the United States will not be fully realized unless HIV disparities associated with SDOH are addressed and every person with or at risk for HIV, benefits from effective treatment and prevention services (i.e., eliminating disparities in treatment and prevention services) [40]. By analyzing trends in disparities that focus on populations known to be disproportionately affected by HIV, we can monitor progress toward NHAS goals and assess if additional interventions are needed to achieve health equity. For example, while community engagement may be a useful strategy that involves local communities in planning and implementing HIV programs to ensure services meet the needs of all Black and White subpopulations; education and outreach developed to provide information about HIV prevention and treatment tailored to White persons aged 35–44 years, White females residing in the Midwest, or Black-White disparities among males aged 13–24 years may be needed. For White males who inject drugs, creating integrated health services that addresses HIV along with other health and social issues, such as mental health and substance use may be needed. Also, for Black-White disparities among persons residing in the West, culturally competent care training for providers to improve communication and trust with diverse populations may be needed. Efforts should prioritize eliminating disparities in treatment and prevention services by taking a comprehensive approach and actively mitigating the social determinants contributing to HIV disparities.