Rapid HIV Transmission Among Hispanic Gay and Bisexual Men in Atlanta, 2021–2022

Georgia's health department did not find these HIV clusters by waiting for someone to report them. It found them in the virus's genetic code. Routine analysis of HIV sequence data revealed, from February 2021, five clusters of rapid transmission concentrated among Hispanic or Latino gay, bisexual and other men who have sex with men (MSM) in metropolitan Atlanta — the first priority clusters in Georgia to be at least 40 percent Hispanic.

Clusters in the code

In Georgia, a cluster is defined by close genetic similarity (within 0.005 nucleotide substitutions per site) among people diagnosed in the last three years; a priority cluster has four or more diagnoses in the last 12 months, a sign of rapid transmission. From 2014 to 2019, HIV diagnoses among Hispanic adolescents and adults in four metro Atlanta counties — Cobb, DeKalb, Fulton and Gwinnett — had already risen from 38.9 to 47.1 per 100,000.

Hard to reach

Outreach to people in the clusters met a limited response, partly because of immigration and deportation fears and a shortage of bilingual staff. Of 52 people eligible for partner services interviews, 34 were interviewed; 16 could not be reached and 2 declined. Of those interviewed, 59 percent met partners online and only 12 percent had ever taken HIV preexposure prophylaxis (PrEP). Among 38 people whose medical charts were available, 26 percent were primarily Spanish-speaking and 32 percent were from Latin American countries.

What people said

CDC and health department staff interviewed 28 Hispanic MSM and one transgender woman, and 65 medical and social service providers. They described barriers:

• few Spanish-speaking staff and little Spanish-language material;
• fear of deportation and other immigration concerns;
• stigma toward MSM and people with HIV, tied to cultural norms about sexuality;
• low awareness of HIV and other sexually transmitted infections, linked to limited access to primary care;
• few HIV services in primary and urgent care, and little outreach aimed at Hispanic MSM.

The response

• regular coordination between the state and the metro Atlanta health districts, and reports to HIV community advisory boards;
• Spanish-language prevention materials stressing that services are available regardless of immigration status, shared on social media and at venues in the clusters' zip codes;
• new partnerships with community organizations serving Hispanic communities, and job postings rewritten to prioritize bilingual hires;
• federal funding, with academic partners, for a culturally matched outreach and bilingual patient navigation program offering "status-neutral" sexual health care to people with and without HIV;
• an at-home HIV and STI self-testing program from June 2022.

Most people in the clusters were virally suppressed — which prevents sexual transmission — yet the clusters were still growing in mid-2022, pointing to a wider network that may include people with undiagnosed HIV. Most large U.S. HIV outbreak responses have focused on people who inject drugs; this one showed that cluster detection can also find fast transmission and service gaps among MSM.

Limits

The community interviews were not with people in the clusters themselves; HIV testing fell during COVID-19, so the clusters may be larger than counted; and incomplete records may understate how many were born abroad or spoke Spanish.

Sources

Based on "Public Health Response to Clusters of Rapid HIV Transmission Among Hispanic or Latino Gay, Bisexual, and Other Men Who Have Sex with Men — Metropolitan Atlanta, Georgia, 2021–2022," by Carlos Saldana, David C. Philpott and colleagues (Georgia Department of Public Health, metro Atlanta health districts, Emory University, CDC), Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; a work of the United States government in the public domain.