In 2021, the estimated number of new HIV infections among persons aged ≥13 years in the United States was 32,100. Within their respective populations, the estimated number of new HIV infections was highest among Black/African American persons (hereafter referred to as Black persons); gay, bisexual, and other men who have sex with men (collectively referred to as MSM); persons living in the south; and persons aged 25–34 years [1]. Among the estimated 1.2 million persons with HIV (PWH) in 2021, 13% were unaware of their HIV status [1]; approximately 40% of new HIV infections are transmitted by persons unaware of their HIV status [2]. Thus, identifying PWH who are unaware of their status through HIV testing, linking them to care, and providing treatment are critical steps for becoming virally suppressed and reducing overall transmission [3].

In 2019, the U.S. Department of Health and Human Services announced Ending the HIV Epidemic in the U.S. (EHE), an initiative aiming to reduce the number of new HIV infections in the United States by 75% by 2025 and by at least 90% by 2030 [4–5]. EHE consists of four pillars: “diagnose all people with HIV as early as possible”; “treat people with HIV rapidly and effectively to reach sustained viral suppression”; “prevent new HIV transmissions by using proven interventions, including pre-exposure prophylaxis and syringe services programs”; and “respond quickly to the potential HIV outbreaks to get needed prevention and treatment services to people who need them” [5]. Phase 1 of EHE focuses on 50 local U.S. jurisdictions (48 counties, the District of Columbia, and San Juan, Puerto Rico) accounting for the majority of new HIV diagnoses and seven states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, South Carolina) with disproportionate occurrence of HIV in rural areas [5].

HIV testing is essential in diagnosing HIV infections; it is the first step of the HIV continuum of care and serves as the basis for the other three EHE pillars [3–4, 6]. Although CDC has recommended HIV screening (i.e., HIV testing at least once, regardless of clinical signs or symptoms) for all persons aged 13–64 years since 2006 [7], the proportion of U.S. adults ever tested for HIV has remained below 50% [8]. Among EHE jurisdictions, only 46.9% of the population in the 50 local jurisdictions and 35.5% in the seven states had ever been tested for HIV infection [9].

EHE specifically calls upon CDC to amplify its existing programs and work with state and local health authorities to “bring HIV testing to all who need it” [4]. CDC has long supported state and local health departments as well as community-based organizations (CBOs) in their HIV prevention efforts through various funding opportunities [10–12]. Following the announcement of EHE, CDC released the Notice of Funding Opportunity (NOFO) “PS20–2010: Integrated HIV Programs for Health Departments to Support Ending the HIV Epidemic in the United States” [13]. This NOFO funds health departments representing the EHE jurisdictions to “implement comprehensive HIV programs, that complement existing programs…to reduce new HIV infections by 75% in 5 years” [13]. Subsequently, CDC released NOFO “PS21–2102: Comprehensive High-Impact HIV Prevention for Community-Based Organizations” [14] to build upon the work of previous funding [11] and in alignment with EHE.

To understand the potential impact of CDC funding on EHE jurisdictions, it would be helpful to identify the distribution of HIV testing services outcomes among CDC-funded health departments and CBOs in EHE jurisdictions and non-EHE jurisdictions. Thus, this manuscript describes selected HIV testing services outcomes related to the “Diagnose” (i.e., HIV tests conducted, persons with newly diagnosed HIV, persons with previously diagnosed HIV) and “Treat” (i.e., linkage to HIV medical care within 30 days of diagnosis, interviewed for partner services) pillars among CDC-funded health departments and CBOs in EHE jurisdictions compared with non-EHE jurisdictions in 2021.

In 2021, two out of three CDC-funded HIV tests conducted and approximately three-quarters of persons newly or previously diagnosed with HIV identified through CDC-funded HIV testing were in EHE jurisdictions. Groups disproportionally affected by HIV infection (e.g., Black persons, Hispanic/Latino persons, persons residing in the South, MSM) were tested and identified with newly or previously diagnosed HIV at greater proportions in EHE jurisdictions versus non-EHE jurisdictions. This indicates that CDC funding opportunities—including those prior to the announcement of EHE [10–12] and after [13–14]—have been reaching disproportionately affected communities [5] and aligning with EHE goals [4].

Higher proportions of CDC-funded HIV tests being conducted in EHE jurisdictions suggests that these high-prevalence jurisdictions [5] may have decided to focus on improving or expanding HIV testing services as a way to support EHE. However, it is possible that this finding may have also been supported by preceding strategies such as CDC’s High-Impact Prevention [16] and the National HIV/AIDS Strategy [17]—both of which lay the foundation for the priorities and goals of EHE [4] by emphasizing identification of new infections and transmission reduction among populations disproportionately affected by HIV. CDC-funded HIV testing in EHE jurisdictions appear to be reaching the populations at greatest risk for HIV as identified by NHAS [17], with the exception of younger persons and transgender persons. However, EHE jurisdictions seem to be prioritizing other populations that are often not reached by HIV testing programs, such as heterosexual women and persons aged ≥50 years. These may be important populations to focus on given that Black women continue to account for over half of new HIV diagnoses among all women [18] and persons aged ≥55 years account for over 10% of new HIV diagnoses [18].

HIV positivity for both new and previous diagnoses was higher in EHE jurisdictions versus non-EHE jurisdictions—and this remained true for most characteristic groups. As aligned with our findings on CDC-funded HIV testing, this suggests that the potential expansions in testing services in EHE jurisdictions are reaching populations with HIV infection. In both EHE and non-EHE jurisdictions, persons aged 25–49 years, Black persons, Hispanic/Latino persons, and PWID had higher positivity than other groups within their respective characteristics. The higher positivity rates in these groups continue to indicate the disproportionate burden of HIV [18] and therefore the need to expand HIV prevention services to reduce the disparities in HIV diagnoses.

More than three-quarters of persons newly diagnosed with HIV were linked to HIV medical care within 30 days of diagnosis; there was no significant difference between EHE and non-EHE jurisdictions. The percentage of persons newly diagnosed with HIV linked to care in 2021 was greater than the percentage of persons newly diagnosed with HIV linked to care in 2019 (71.4%) [19]. Although the continuation of the COVID-19 pandemic may have generally presented challenges to medical care access, having a fewer number of newly diagnosed individuals in 2021 may have allowed HIV prevention programs to provide greater support of linkage to care, regardless of whether the program was in an EHE or non-EHE jurisdiction. Nevertheless, the percentage of persons newly diagnosed with HIV linked to care—and especially the percentage of persons previously diagnosed with HIV linked to care—in EHE and non-EHE jurisdictions was lower than the NHAS 2025 target of 95% for linkage to care within one month [20], indicating that there is still room for improvement. This is especially true for EHE jurisdictions as they have a higher prevalence of PWH and thus a greater number of persons to link to HIV medical care.

CDC recommends that all persons newly diagnosed with HIV be contacted and interviewed for partner services as soon as possible to elicit information about their sexual or needle-sharing partners and to assess their own service needs [15]. The proportion of persons newly diagnosed with HIV interviewed for partner services was greater in non-EHE jurisdictions than in EHE jurisdictions. This is concerning given that EHE jurisdictions have a greater prevalence of HIV infection where it is vital to elicit information about partners of persons newly diagnosed with HIV to prevent HIV acquisition or identify more persons with HIV infection. The continuing disruption in field work and deployment of partner services field workers to the COVID-19 response, as well as the overall higher numbers of index persons to interview and partners to follow up with, may have contributed to lower levels in EHE jurisdictions, especially as some EHE jurisdictions had high burdens of both HIV and COVID-19. The proportions of persons previously diagnosed with HIV interviewed for partner services was lower than those for persons newly diagnosed with HIV. This may have also been due to resource constraints, as programs may have had to prioritize identifying and interviewing persons newly diagnosed with HIV.

This analysis is subject to a few limitations. First, NHM&E is comprised of CDC-funded HIV tests only and thus are not representative of all HIV tests conducted in the United States. Second, NHM&E HIV testing data are collected at the test-level and not the person-level (e.g., a person could be tested for and diagnosed with HIV through CDC-funded HIV testing more than once). Third, the percentage of persons linked to HIV medical care within 30 days and the percentage of persons interviewed for partner services are calculated by excluding tests with missing or unknown outcome data from the denominator, which may overestimate the outcomes. Fourth, given the large sample sizes in our dataset, statistically significant differences may need to be interpreted with caution. Finally, CDC-funded HIV prevention services continued to be impacted by the COVID-19 pandemic in 2021, leading to fewer number of tests conducted and persons identified with newly diagnosed HIV than in 2019 [21–22]. However, the distribution of HIV testing services outcomes by demographic and other characteristics were similar in 2019 and 2021 [19, 22].

In 2021, CDC-funded health departments and CBOs in EHE jurisdictions conducted more CDC-funded HIV tests and identified more persons newly and previously diagnosed with HIV than non-EHE jurisdictions. In order to achieve EHE goals [4], EHE jurisdictions will first have to continue identifying HIV infections by expanding HIV testing programs through such strategies as routine opt-out HIV screening in healthcare settings, HIV self-testing, HIV testing in retail pharmacies, and mobile/outreach testing [6]. Upon identification of persons with diagnosed HIV, EHE jurisdictions can promote linkage to HIV medical care by streamlining intake processes and providing navigation services [23], as well as employing interventions that support rapid uptake of treatment from CDC’s Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention [24]. Implementing Data-to-Care programs among persons with previously diagnosed HIV not in care [23] may be beneficial as well. Furthermore, EHE jurisdictions can ensure that HIV partner services programs have sufficient resources to conduct their activities, especially among programs most impacted by disruptions of field work and staffing limitations during the COVID-19 pandemic.