HomeMy WebLinkAbouthiv-report-2021-2023-archive HIV in Alameda County, 2021-2023 i
HIV IN ALAMEDA
COUNTY, 2021-2023
Alameda County Public
Health Department
HIV Epidemiology &
Surveillance Unit
HIV in Alameda County, 2021-2023 ii
HIV in Alameda County, 2021-2023
February 2025
HIV Epidemiology and Surveillance Unit
Division of Communicable Disease Control and Prevention
Alameda County Public Health Department
HIV in Alameda County, 2021-2023 iii
Alameda County Public Health Department
Director
Health Officer
Deputy Director
Division of Communicable Disease Control and Prevention
Director
STD/HIV Controller
Epidemiology Research Scientist
HIV Epidemiology and Surveillance Unit
Director
Epidemiologist
Public Health Investigators
Kimi Watkins-Tartt
Nicholas J. Moss, MD, MPH
George Ayala, PsyD
Darlene Fujii, RD, EdM
Eileen F. Dunne, MD, MPH, FIDSA
Emily Yette, PhD, MPH
Daniel Allgeier, MPH
Gabriella Cleary, MPH
Oliver Heitkamp
Maria Hernandez
Liana Ceja
HIV in Alameda County, 2021-2023 iv
Alameda County Public Health Department
HIV Epidemiology and Surveillance Unit
1100 San Leandro Blvd, 3rd Floor
San Leandro, CA 94577
Phone: (510) 268-2372
Fax: (510) 208-1278
Email: Daniel.Allgeier@acgov.org
Acknowledgements
This report was produced by the HIV Epidemiology and Surveillance Unit. Daniel Allgeier, MPH, Director,
provided overall direction and oversight of surveillance and data analysis; and contributed to writing and
review. Epidemiologist Gabriella Cleary, MPH was the major contributor to analysis, graphics, writing,
editing and layout. The HIV surveillance team collected and documented case surveillance data included in
this report. Thank you to George Ayala, Eileen Dunne, Steve Gibson, Curtis Moore, Dot Theodore, and
Emily Yette for their review and input on this report.
Front Cover Photo by Lyrinda Snyderman: https://www.flickr.com/photos/lyrinda/49928964577/
Table of Contents Photo by Christian Emmel: https://www.flickr.com/photos/
christian_emmel/2211628686/
List of Figures Photo by Scot Hacker: https://www.flickr.com/photos/shacker/53621820374/
Background Photo by Jeremy Brooks: https://www.flickr.com/photos/jeremybrooks/8188752171/
New Diagnosis Photo by Myla and Wes: https://www.flickr.com/photos/mylawes/3530822779/
People Living with HIV Photo by Caleb Carson: https://www.flickr.com/photos/caleblevy/52284780410/
Continuum of Care Photo by Caleb Carson: https://www.flickr.com/photos/caleblevy/52503212024/
Appendix A Photo by Jason Jenkins: https://www.flickr.com/photos/jdub1980/6036780253/
Appendix B Photo by James Ala: https://www.flickr.com/photos/spincitysd/5724542850/
Appendix C Photo by Lonewolfpics: https://www.flickr.com/photos/jghflicpics/7523167050/
Bibliography Photo by Charlie Day: https://www.flickr.com/photos/60700203@N03/52525245119/
Back Cover Photo by Omar Ronquillo: https://www.flickr.com/photos/116218346@N05/16819054500/
This report is available online at http://www.acphd.org/data-reports/reports-by-topic/communicable-
disease.aspx#HIV
Suggested citation for this report:
Alameda County Public Health Department. HIV in Alameda County, 2021-2023.
http://www.acphd.org/data-reports/reports-by-topic/communicable-disease.aspx#HIV. Published
February 2025. Accessed [date].
HIV in Alameda County, 2021-2023 v
Table of Contents
1. Background 1
Overview of this Report 1
HIV/AIDS 1
Definitions Used in this Report 2
2. New Diagnoses 4
Characteristics of New Diagnoses 5
Timeliness of Diagnosis 17
Late Diagnosis 17
3. People Living with HIV 20
Characteristics of People Living with HIV 21
Deaths Among Alameda County Residents Ever Diagnosed with AIDS 29
HIV-MPOX Coinfection 31
4. Continuum of Care 34
The Overall Continuum of Care 35
Linkage to Care 35
Retention in Care 38
Virologic Status 44
Appendix A: Technical Notes 49
Data Sources 49
Statistical Analysis 49
Data Suppression Rules 49
Appendix B: Reporting Requirements 51
Health Care Providers 51
Laboratories 52
Appendix C: Surveillance in Alameda County 54
Security and Confidentiality of Data 54
Limitations of Surveillance Data and of County Analysis 55
Bibliography 56
HIV in Alameda County, 2021-2023 vi
List of Figures
1.1: Regions of Alameda County 3
1.2: Neighborhoods in the City of Oakland 3
2.1: New Diagnosis by Year, Alameda County, 2007-2023 5
2.2: Diagnosis Rates by 3-year Period, Alameda County, 2006-2023 5
2.3: New Diagnosis by Race/Ethnicity, Alameda County, 2021-2023 6
2.4: Percent of New Diagnoses by Race/Ethnicity, Alameda County, 2021-2023 7
2.5: Average Diagnosis Rates by Race/Ethnicity, Alameda County, 2021-2023 7
2.6: Diagnosis Rates by Year and Race/Ethnicity, Alameda County, 2006-2023 8
2.7: New Diagnoses by Sex at Birth, Alameda County, 2021-2023 8
2.8: New Diagnosis Rates by Year and Sex at Birth, Alameda County, 2006-2023 9
2.9: New Diagnoses by Gender, Alameda County, 2021-2023 9
2.10: Newly Diagnosed by Age at Diagnosis, Alameda County, 2021-2023 10
2.11: Percent of Newly Diagnosed by Age at Diagnosis, Alameda County, 2021-2023 10
2.12: Average Diagnosis Rate by Age Group at Diagnosis, Alameda County, 2021-2023 11
2.13: Diagnosis Rate by Year and Age (highest) at Diagnosis, Alameda County, 2006-2023 12
2.14: Diagnosis Rate by Year and Age (lowest) at Diagnosis, Alameda County, 2006-2023 12
2.15: New Diagnoses by Transmission Category, Alameda County, 2021-2023 13
2.16: Percent of New Diagnoses by Transmission Category, Alameda County, 2021-2023 13
2.17: New Diagnoses by Transmission Category and Race/Ethnicity Among Males, Alameda
County, 2021-2023 14
2.18: New Diagnoses by Transmission Category and Age Among Males, Alameda County, 2021-
2023 14
HIV in Alameda County, 2021-2023 vii
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2.19: Geographic Distribution of New HIV Diagnoses by Residence at HIV Diagnosis, Alameda
County, 2021-2023
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2.20: Residence at HIV Diagnosis, Oakland, and Surrounding Area, 2021-2023 16
2.21: Late Diagnosis by Race/Ethnicity, Alameda County, 2020-2022 17
2.22: Late Diagnosis by Birth Sex, Alameda County, 2020-2022 18
2.23: Late Diagnosis by Age, Alameda County, 2020-2022 18
2.24: Late Diagnosis by Year, Alameda County, 2006-2023 19
3.1: PLHIV by Sex Assigned at Birth, Alameda County, Year-End 2023 21
3.2: Prevalence Rate by Year and Sex Assigned at Birth, Alameda County, 2010-2023 21
3.3: Prevalence Rate by Sex Assigned at Birth, Alameda County, Year-End 2023 21
3.4: PLHIV by Gender, Alameda County, Year-End 2023 22
3.5: Percent of PLHIV by Gender, Alameda County, Year-End 2023 22
3.6: PLHIV by Race/Ethnicity, Alameda County, Year-End 2023 23
3.7: Percent of PLHIV by Race/Ethnicity, Alameda County, Year-End 2023 23
3.8: Prevalence Rates by Race/Ethnicity, Alameda County, Year-End 2023 24
3.9: Prevalence Rates by Race/Ethnicity and Year, Alameda County, 2010-2023 24
3.10: Number of PLHIV by Age, Alameda County, Year-End 2023 25
3.11: Prevalence Rate by Age, Alameda County, Year-End 2023 25
3.12: Percent PLHIV by Age, Alameda County, Year-End 2023 25
3.13: Prevalence Rate by Age and Year, Alameda County, 2010-2023 (younger cohort) 26
3.14: Prevalence Rate by Age and Year, Alameda County, 2010-2023 (older cohort) 26
3.15: Prevalence of HIV by Census Tract of Residence, Alameda County, Year-End 2023 27
3.16: Prevalence of HIV by Census Tract of Residence, Oakland and Surrounding Area, Year-End
2023 28
HIV in Alameda County, 2021-2023 viii
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3.17: Death Rate by Year among Alameda County Residents Diagnosed with AIDS, Alameda
County, 1983-2023 29
3.18: Deaths by Year among Alameda County Residents Diagnosed with AIDS, Alameda County,
1983-2023 30
3.19: Death Rate among PLHIV by Year, Alameda County, 2006-2023 30
3.20: MPOX Cases by Coinfection with HIV, Alameda County, Year-end 2023 31
3.21: MPOX Cases with HIV Coinfection by Gender, Alameda County, Year-end 2023 31
3.22: MPOX Cases with HIV Coinfection by Race/Ethnicity, Alameda County, Year-end 2023 32
3.23: MPOX Cases with HIV Coinfection by Age, Alameda County, Year-end 2023 32
3.24: MPOX Cases with HIV Coinfection by Transmission, Alameda County, Year-end 2023 33
4.1: The Continuum of HIV Care in Alameda County, 2021-2023 35
4.2: Linkage to Care by Inclusion of Date of Diagnosis Lab, Alameda County, 2021-2023 36
4.3: Linkage to Care in 30 Days by Race/Ethnicity, Alameda County, 2021-2023 36
4.4: Linkage to Care in 30 Days by Age, Alameda County, 2021-2023 37
4.5: Linkage to Care in 30 Days by Sex at Birth, Alameda County, 2021-2023 37
4.6: Linkage to Care in 30 Days by Gender, Alameda County, 2021-2023 37
4.7: Linkage to Care in 30 Days by Transmission Category, Alameda County, 2021-2023 38
4.8: Engagement and Retention in Care by Race/Ethnicity, Alameda County, 2022 39
4.9: Engagement and Retention in Care by Age, Alameda County, 2022 39
4.10: Engagement and Retention in Care by Birth Sex, Alameda County, 2022 40
4.11: Engagement and Retention in Care by Gender, Alameda County, 2022 40
HIV in Alameda County, 2021-2023 ix
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4.12: Retention in Care by City/Place, Alameda County, 2022 41
4.13: Retention in Care by Region, Alameda County, 2022 42
4.14: Retention in Care by Oakland Neighborhood, Alameda County, 2022 42
4.15: Engagement and Retention by Nativity Status among PLHIV, Alameda County, 2022 43
4.16: Engagement and Retention by Region of Origin among PLHIV, Alameda County, 2022 43
4.17: Viral Suppression by Race/Ethnicity, Alameda County, 2022 44
4.18: Viral Loads by Race/Ethnicity, Alameda County, 2022 44
4.19: Viral Suppression by Age, Alameda County, 2022 45
4.20: Viral Loads by Age, Alameda County, 2022 45
4.21: Viral Suppression by Birth Sex, Alameda County, 2022 45
4.22: Viral Suppression by Gender, Alameda County, 2022 45
4.23: Percentage of PLHIV with Viral Suppression by City/Place, Alameda County, 2022 46
4.24: Percentage of PLHIV with Viral Suppression by Region, Alameda County, 2022 47
4.25: Percentage of PLHIV with Viral Suppression by Oakland Neighborhood, Alameda County,
2022 47
4.26: Progression Through the Continuum of HIV Care Among PLHIV, Alameda County, 2022 48
HIV in Alameda County, 2021-2023 1
Overview of this Report
This report is based on human immunodeficiency virus (HIV) case surveillance in Alameda County. It
summarizes data on HIV in 3 chapters as described below.
2. New Diagnoses: This chapter describes patterns of HIV diagnosis in Alameda County, characterizing
those who were recently diagnosed according to demographic factors, risk factors and stage of disease.
3. People Living with HIV: The second chapter of the report describes the characteristics of all people
known to be living with HIV disease (PLHIV) in Alameda County. This chapter describes the total
burden of HIV disease in the county and how it varies by demographic factors as well as by geography.
It also describes changes in mortality rates (deaths) over time among those ever diagnosed with
Acquired Immune Deficiency Syndrome (AIDS).
4. The Continuum of HIV Care: This chapter presents the continuum of HIV care in Alameda County.
Modern medical treatments for HIV can halt the progression of the disease and prevent its spread, but
not all persons living with HIV receive effective treatment. The continuum of HIV care (also known as
the “HIV care cascade”) is a framework that presents different indicators of engagement in HIV care
among people living with HIV, including linkage to care, retention in care, and viral suppression.
HIV
HIV attacks the immune system, weakening it over time such that people living with HIV become
increasingly susceptible to opportunistic infections and other medical conditions. The most advanced stage
of infection, when the immune system is weakest, is called AIDS. HIV treatments are highly effective in
controlling HIV replication and reducing transmission, but they do not eliminate viral infection. HIV is
typically transmitted through sex, contaminated needles, or spread from birthing parent to fetus during
pregnancy.
Background
HIV in Alameda County, 2021-2023 2
Definitions Used in this Report
Stages of HIV Infection
For surveillance purposes, HIV disease progression is classified into 4 stages, from acute infection (Stage 0)
to AIDS (Stage 3). In this report, we use “HIV” to refer to HIV disease at any stage (including Stage 3/
AIDS) and AIDS to refer specifically to Stage 3 HIV disease. We use the acronym “PLHIV” to refer to all
people living with HIV disease, regardless of stage.
Case Definition
All reported HIV cases must meet the Centers for Disease Control and Prevention (CDC) case definition
based on laboratory or clinical criteria.1 Clinical criteria include a medical provider diagnosis and evidence of
HIV treatment, unexplained low CD4 count, or opportunistic infection. The full criteria may be found at
https://www.cdc.gov/hivnexus/hcp/guidelines/?CDC_AAref_Val=https://www.cdc.gov/hiv/clinicians/
guidelines/index.html.
Transmission Category
For surveillance purposes, each reported HIV case must be classified according to their risk factors for
acquiring HIV. Cases with multiple risk factors are assigned a transmission category, the risk factor most
likely to have resulted in HIV transmission according to a hierarchy developed by the CDC. In this context,
“heterosexual contact” refers to sexual contact with a partner of the opposite sex with a known risk factor
for HIV. In some cases, partners’ risk factors are unknown, leaving some heterosexual cases without known
HIV risk factors. Such cases are assigned to the “unknown” transmission category. The only exception is
when a case’s sex at birth is female and she reported sex with males, in which case she is presumed to have
been infected through heterosexual contact in accordance with CDC-accepted guidance set by the Council
of State and Territorial Epidemiologists.2
Demographics
Demographic data in this report are based on investigations of medical records. Although the transgender
community is highly impacted by HIV, data on current gender identity are not reliably captured in medical
records. For this reason, analyses are presented for sex assigned at birth as well as known current gender.
Data from racial/ethnic groups in which there were very small numbers were combined for these analyses
for the purpose of maintaining privacy. Asians and Pacific Islanders are combined into a single category.
American Indians, Alaskan Natives, and those identifying with multiple races are combined along with those
of unknown race into another group (“Other/Unk”). In tables and charts, the category “Asians and Pacific
Islanders” is abbreviated “API” and “African American” is abbreviated “AfrAmer”. Analyses that are
broken out by subgroup (e.g., race/ethnicity) are presented along with the overall group total (e.g., all races)
for comparison.
Geographic Area
Residential addresses are geocoded to census tract and city/Census-designated place. Region and
neighborhood boundaries established by the Alameda County Community Assessment, Planning, and
Evaluation (CAPE) unit based on census tract aggregates are used. These geographic areas are shown in
Figures 1.1 and 1.2.
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HIV in Alameda County, 2021-2023 3
Figure 1.1: Regions of Alameda County
Figure 1.2: Neighborhoods in the City of Oakland
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HIV in Alameda County, 2021-2023 4
Alameda County Public Health Department (ACPHD) monitors the HIV epidemic through mandated
reports of new diagnoses and laboratory results. Estimating the true incidence rate of new HIV
transmissions is complex due to the variable time interval between when a person becomes infected and
when their infection is diagnosed. However, surveillance data reliably describe all new HIV diagnoses and
diagnosis rates. In 2022, there were an estimated 38,043 new diagnoses of HIV in the US for an overall
diagnosis rate of 11.3 per 100,000 persons.3 Among people newly diagnosed in 2022, 79% identified as men,
18% as women, and 3% as transgender. The age group with the highest rates for people 13 years and older
were among those aged 25 to 34 (30.8 per 100,000). The racial/ethnic groups with the highest rates were
African Americans and Latinx (41.6 and 23.4 per 100,000), and the U.S. regions with the highest rates of
new diagnoses were the South and West (18.2 and 11.8 per 100,000). Gay and bisexual men who have sex
with men, including those who inject drugs, accounted for 67% of all new diagnoses and 82% of newly
diagnosed males. Heterosexual contact accounted for 83% of newly diagnosed females.3
In California, an estimated 4,882 new diagnoses for an overall statewide rate of 12.2 diagnoses per 100,000
in 2022.4 In Alameda County, the average annual diagnosis rate calculated over the 3-year period from 2021
to 2023 was 11.8 diagnoses per 100,000.
America’s HIV Epidemic Analysis Dashboard (AHEAD) displays HIV data and goals for 57 priority areas,
including Alameda County. AHEAD tracks national and jurisdictional progress for six Ending the HIV
Epidemic (EHE) indicators that aim to reduce new HIV infections in the US by 75% in five years and by
90% in 10 years. According to the dashboard, Alameda County’s knowledge of status – the estimated
percentage of people with HIV who have received an HIV diagnosis – was 90.1% [CI 82.5-99.3] in 2022.4
This chapter describes HIV in Alameda County by examining the characteristics of new diagnoses, new
diagnosis rates, and the timeliness of diagnoses by demographic characteristics.
New Diagnoses
HIV in Alameda County, 2021-2023 5
Figure 2.2: Diagnosis Rates by 3-year Period, Alameda County, 2006-2023
Characteristics of New Diagnoses
Since HIV became reportable by name in California in 2006, between 200 and 300 new cases of HIV
disease have been reported each year among Alameda County residents with the exception of 2020 (160
new diagnoses) and the most recent year, 2023 (190 new diagnoses). The substantial drop in number of
newly diagnosed cases in 2020 may be attributed to the impact of the COVID-19 pandemic. Seeking
medical testing as well as routine testing outreach activities was limited due to shelter-in-place orders and
social distancing. It is probable that many new cases of HIV went undiagnosed in 2020. Social restrictions
may have also reduced the number of high-risk sexual interactions between casual partners, possibly
resulting in fewer transmissions. Additionally, reduced case reporting capability during the pandemic could
have contributed to the apparent decline in cases. The data to quantify the role of these factors is not yet
available through routine surveillance methods or other sources.
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Figure 2.1: New Diagnosis by Year, Alameda County, 2007-2023
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Diagnosis rates are not equivalent to HIV incidence rates. Trends in diagnosis rates may reflect changes in
HIV incidence over time but may also reflect changes in HIV testing practices, access to care, stigma, and
other barriers to testing. For example, HIV incidence could decrease while HIV diagnosis rates increase if
more HIV-unaware persons are tested and diagnosed. Due to the relatively small number of diagnoses
occurring in Alameda County in any given year, annual diagnosis rates are statistically unstable.
Diagnosis rates were calculated using new case counts over a 3-year period to accrue large enough numbers
to calculate statistically stable rates. The rate of new diagnoses across Alameda County has been steadily
decreasing by an average annual change of -2.95%, starting at 18.5 per 100,000 in 2006-2008 to 11.8 per
100,000 in 2021-2023.
Figure 2.3: New Diagnosis by Race/Ethnicity, Alameda County, 2021-2023
When broken down by race/ethnicity, the largest number of new diagnoses were among Latinx residents,
accounting for 42.4% of new cases. This is a shift from previous years where African American residents
have historically represented the plurality of new diagnoses. Asian and Pacific Islander residents continue to
have the fewest new diagnoses despite making up a large portion of Alameda County’s population. The
category Other/Unknown includes those who identify as American Indian, Other, or Multiracial, and those
for whom race/ethnicity is unknown.
HIV in Alameda County, 2021-2023 7
Despite having the second most new diagnoses, African American residents still have the highest rate of
new diagnoses in Alameda County with 37.5 new diagnoses per 100,000 residents, a rate 5.6 times higher
than White residents and over 10 times higher than Asian and Pacific Islander residents.
Figure 2.5: Average Diagnosis Rates by Race/Ethnicity, Alameda County, 2021-2023
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Figure 2.4: Percent of New Diagnoses by Race/Ethnicity, Alameda County, 2021-2023
HIV in Alameda County, 2021-2023 8
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Figure 2.7: New Diagnoses by Sex at Birth, Alameda County, 2021-2023
However, the new diagnosis rate among African American residents has been declining since 2006
with an average annual change of -3.6%, driving the county-wide decline in diagnosis rates. The de-
cline is even more dramatic among African American people designated female at birth with an aver-
age annual change of -5.8%. In contrast, Latinx have experienced an average annual increase of 2.0%
with Latinos designated male at birth increasing at 2.3%. The rate among Latinas designated female
at birth has been increasing by an average of 6.5% a year since 2013, however, these counts are still
relatively low and therefore the rates are not as stable. This trend among Latinx, while noticed over
the last few years, has only become statistically significant when 2023 data is considered.
Figure 2.6: Diagnosis Rates by Year and Race/Ethnicity, Alameda County, 2006-2023
HIV in Alameda County, 2021-2023 9
Figure 2.8: New Diagnosis Rates by Year and Sex at Birth, Alameda County, 2006-2023
Note: “Sex” here refers to sex assigned at birth.
Figure 2.9: New Diagnoses by Gender, Alameda County, 2021-2023
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Data for current gender has historically been inaccurate and continues to be flawed, likely under-
counting the number of transgender individuals being reported, but the data collection has been im-
proving and state and local jurisdictions make greater efforts to accurately represent people’s gender
identity. In the figure above, transgender individuals were grouped with other non-binary gender
identities as well as with individuals believed to be transgender, but not confirmed from demograph-
ic information reported in lab records. While imperfect, this provided the best estimate for the non-
binary community. Between 2021-2023, 2.4% of new diagnoses were among transgender individuals,
a majority of which were transwomen.
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Figure 2.10: Newly Diagnosed by Age at Diagnosis, Alameda County, 2021-2023
Figure 2.11: Percent of Newly Diagnosed by Age at Diagnosis, Alameda County, 2021-2023
HIV in Alameda County, 2021-2023 11
Nearly 2/3 of new diagnoses were among those younger than 40 years, with the largest group between 30-
39 years. The median age of new diagnoses was 34 years and the average age was 36.6. The highest
diagnosis rate was among those 25-29 years of age with 29.7 per 100,000, more than twice the county-wide
rate in 2021-2023.
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Figure 2.12: Average Diagnosis Rate by Age Group at Diagnosis, Alameda County, 2021-2023
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Figure 2.13: Diagnosis Rate by Year and Age (highest) at Diagnosis, Alameda County, 2006-2023
Diagnosis rates over time were split across two graphs to avoid having the scale of the higher rates flat-
ten out the trends among the lower rates. The age groups with the higher rates include ages 20-24, 25-
29, and 30-39 years. Rates among these age groups did not significantly change over time despite the
overall trend going down.
Figure 2.14: Diagnosis Rate by Year and Age (lowest) at Diagnosis, Alameda County, 2006-2023
The age groups with the lowest rates include ages 13-19, 40-49, and 50 and over years. All three have
seen declining trends in diagnosis rates since 2006 with average annual changes of -5.8%, -5.1%, and -
4.7%, respectively.
HIV in Alameda County, 2021-2023 13
Figure 2.15: New Diagnoses by Transmission Category, Alameda County, 2021-2023
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Almost two-thirds (65.1%) of new diagnoses during 2021 to 2023 were among men who have sex with
men (MSM). When this category is combined with men who have sex with men who also are people
who inject drugs (PWID), this group is more than 2/3 of all new diagnoses. The category “Heterosexual
Contact” indicates that the person had heterosexual contact with someone known to be HIV positive
whereas “Presumed Heterosexual Contact” indicates that a person assigned female at birth or
transgender woman had a heterosexual male partner with an unknown HIV status and no other likely
exposure.
Figure 2.16: Percent of New Diagnoses by Transmission Category, Alameda County, 2021-2023
HIV in Alameda County, 2021-2023 14
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Figure 2.17: New Diagnoses by Transmission Category and Race/Ethnicity Among Males, Alameda County, 2021-2023
Looking at racial/ethnic differences among men who reported having sex with other men versus men
who did not, Latino men made up a higher proportion of men who have sex with other men (48.6%)
than men who did not report sex with other men (35.4%) and African American men made up a smaller
proportion of men who had sex with other men (23.5%) than men who did not report sex with other
men (34.3%). When looking at age differences, younger age groups were more represented among men
who have sex with other men than older age groups.
Figure 2.18: New Diagnoses by Transmission Category and Age Among Males, Alameda County, 2021-2023
HIV in Alameda County, 2021-2023 15
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Figure 2.19: Geographic Distribution of New HIV Diagnoses by Residence at HIV Diagnosis, Alameda County, 2021-
2023
New diagnoses of HIV were most concentrated in the Oakland area and central county regions (as de-
fined in Figure 1.1 on page 3). This distribution mirrors the major population centers in the county and
can help guide the distribution of services for HIV care and prevention.
HIV in Alameda County, 2021-2023 16
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Figure 2.20: Residence at HIV Diagnosis, Oakland, and Surrounding Area, 2021-2023
The highest concentration of new diagnoses in the Oakland area was in Downtown/Chinatown
and Elmhurst in East Oakland. The Oakland Hills had the lowest percent of new HIV diagnoses
in the region.
HIV in Alameda County, 2021-2023 17
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Timeliness of Diagnosis
Diagnosis of HIV early in the course of infection is an important component of effective HIV prevention
and treatment with highly active antiviral medications as early intervention generally reduces both the risk of
transmission to others and the impact of HIV infection on a person's health.
Late Diagnosis
A key indicator of late HIV diagnosis is the time to progression to AIDS (stage 3 HIV infection). A
diagnosis is deemed late if AIDS is diagnosed at the same time as a person's initial HIV diagnosis or if the
person progresses to AIDS within one year of the initial HIV diagnosis. The analyses presented in this
section are for the years 2020 to 2022 in order to provide a full year of data following diagnosis. Apparent
differences should be interpreted with caution due to the small numbers of diagnoses seen in some
subgroups, resulting in statistical instability.
The highest percentage of late diagnoses, at 28.7% of new diagnoses, occurred among White residents. The
lowest percent of diagnoses that were considered late diagnoses was among Asian/Pacific Islander
residents, at 16.4%. Late diagnosis percent was higher among people designated as male at birth, however,
the difference between males and females is not statistically significant.
Figure 2.21: Late Diagnosis by Race/Ethnicity, Alameda County, 2020-2022
HIV in Alameda County, 2021-2023 18
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Figure 2.22: Late Diagnosis by Birth Sex, Alameda County, 2020-2022
Figure 2.23: Late Diagnosis by Age, Alameda County, 2020-2022
Almost 41% of new diagnoses among people aged 50 years and older were late diagnoses, the
highest within any age group. This makes intuitive sense given that more time could have
passed since the transmission event occurred if a person is older. The youngest age group, 13
to 19 years of age has an elevated late diagnosis percent, but this is an unstable estimate given
the smaller number of cases in the cohort.
HIV in Alameda County, 2021-2023 19
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Figure 2.24: Late Diagnosis by Year, Alameda County, 2006-2023
The percentage of late diagnosis has declined since 2006 when it was over 40% to now 23.7%.
After a relatively steep decline percentages have plateaued around 20% for the past several
years.
HIV in Alameda County, 2021-2023 20
In the United States, there were an estimated 1,108,292 persons aged 13 years or older living with diagnosed
HIV at the end of 2022 for an overall rate of 387.9 per 100,000. People who identified as men made up 76%
of all people living with HIV (PLHIV). The highest prevalence rates were among those aged 55 to 59 (753.4
per 100,000), African Americans and Latinx (1,036.6 and 423 per 100,000 respectively), and in the Northeast
and South (414.3 and 393.5 per 100,000 respectively).3 At year-end 2022, California had an estimated
142,700 people living with HIV for a statewide prevalence of 355.6 per 100,000 population. HIV prevalence
among cisgender women in California is 83.9 per 100,000 compared to 173.5 per 100,000 among cisgender
women nationally.5 At year-end 2023 in Alameda County, the prevalence of HIV was 368.1 per 100,000
residents.
This chapter examines the prevalence, or the proportion of people in Alameda County living with HIV
infection, reflecting the overall impact of HIV in the population. Data presented do not include people
living with HIV with undiagnosed infection but include all those with diagnosed HIV (including newly
diagnosed), regardless of the stage of HIV infection. First, characteristics of people living with HIV in the
county are presented. Then, the prevalence of HIV disease in different subpopulations is described. Finally,
the mortality (deaths) among people living with HIV ever diagnosed with AIDS is described.
People Living with HIV
HIV in Alameda County, 2021-2023 21
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Characteristics of People Living with
HIV
At the end of 2023, there were an estimated 6,331 people
living with HIV in Alameda County.
As with the distribution by sex among new diagnoses of
HIV, people living with HIV in Alameda County at year-
end 2023 were predominantly male (83.4%). This
distribution has remained relatively constant since 2010.
Figure 3.1: PLHIV by Sex Assigned at
Birth, Alameda County, Year-End 2023
Note: “Sex” refers to sex assigned at birth.
Figure 3.2: Prevalence Rate by Year and Sex Assigned
at Birth, Alameda County, 2010-2023
Figure 3.3: Prevalence Rate by Sex Assigned at Birth,
Alameda County, Year-End 2023
The prevalence rate among people assigned male at birth is over five times as high as those assigned female at birth.
While the rate among men has increased since 2010, the rate among women has remained roughly the same.
HIV in Alameda County, 2021-2023 22
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Figure 3.4: PLHIV by Gender, Alameda County, Year-End 2023
Figure 3.5: Percent of PLHIV by Gender, Alameda County, Year-End 2023
Data regarding gender identity has been difficult to reliably collect and analyze. It is likely the number of people living
with HIV identifying as transgender is undercounted, however, greater effort has been made in recent years to im-
prove reporting of current gender. Even with the correct count, a prevalence rate cannot be calculated due to a lack of
denominators. With those caveats in mind, an estimated 2.2% of people living with HIV were identified as
transgender or another non-binary gender identity.
HIV in Alameda County, 2021-2023 23
Figure 3.6: PLHIV by Race/Ethnicity, Alameda County, Year-End 2023
People living with HIV in Alameda County were predominantly African American (36.8%), White
(26.3%), or Latino (24.7%). API comprised a smaller proportion of people living with HIV (7.4%)
despite making up a third of Alameda County’s population.
Figure 3.7: Percent of PLHIV by Race/Ethnicity, Alameda County, Year-End 2023
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Figure 3.8: Prevalence Rates by Race/Ethnicity, Alameda County, Year-End 2023
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Figure 3.9: Prevalence Rates by Race/Ethnicity and Year, Alameda County, 2010-2023
African Americans had a 3.75 times higher burden of HIV prevalence compared to the next most impacted
racial group, Latinx. Prevalence was lowest among API. It is worth noting that while the prevalence rate
continues to increase among African Americans, the diagnosis rate continues to fall. This is related to life
expectancy for those living with HIV improving over time due to effective medication.
HIV in Alameda County, 2021-2023 25
Figure 3.10: Number of PLHIV by Age, Alameda
County, Year-End 2023
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Figure 3.12: Percent PLHIV by Age, Alameda County, Year-End 2023
Over half of people living with HIV are 50 years and older in Alameda County. Fewer than a quarter
were in their 30s or younger. The median age was 53 and the mean was 50.5 in 2023.
Figure 3.11: Prevalence Rate by Age, Alameda
County, Year-End 2023
HIV in Alameda County, 2021-2023 26
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Figure 3.14: Prevalence Rates by Age and Year, Alameda
County, 2010-2023 (older cohort)
Prevalence rates have been increasing among those 60 years and over and 30-39 years of age. The
prevalence rates in those aged 40-49 years have decreased from around 800 per 100,000 in 2010 to 513.9
per 100,000 in 2023. Of course, individuals will move into older age groups as time passes, contributing to
higher prevalence rates among older age groups. HIV prevalence was higher in each successive age group
through ages 50-59, ranging from 15.0 per 100,000 youth aged 13 to 19 to a high of 841.3 per 100,000
people aged 50 to 59 years. The number of children aged 0 to 12 living with HIV was too low to estimate
a statistically reliable prevalence rate. The increasing prevalence of HIV with age is consistent with the
greatly improved survival of people living with HIV in the post-antiretroviral therapy (ART) era.
Disparities in prevalence rates by race/ethnicity were more pronounced among females than males. While
prevalence in 2023 was almost four times higher among African American males (2355.3 per 100,000)
compared to White males (600.0 per 100,000), it was 10 times higher among African American females
(714.3 per 100,000) compared to White females (70.0 per 100,000). Additionally, although HIV prevalence
was only 11.3% higher among Latino males (667.8 per 100,000) than White males, prevalence was 34.9%
higher among Latina females (94.4 per 100,000) than White females.
Figure 3.13: Prevalence Rates by Age and Year, Alameda
County, 2010-2023 (younger cohort)
HIV in Alameda County, 2021-2023 27
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The city of Emeryville had the highest HIV prevalence within Alameda County (1240.5 per 100,000),
followed by Oakland (760.9 per 100,000), San Leandro (381.5 per 100,000), and Berkeley (375.8 per
100,000). Among the Oakland neighborhoods, West Oakland, Downtown, and Chinatown had the highest
HIV prevalence, up to 2870.7 per 100,000, which translates to almost 3% of all residents in a census tract.
Figure 3.15: Prevalence of HIV by Census Tract of Residence, Alameda County, Year-End 2023
HIV in Alameda County, 2021-2023 28
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Figure 3.16: Prevalence of HIV by Census Tract of Residence, Oakland and Surrounding Area, Year-End 2023
HIV in Alameda County, 2021-2023 29
Deaths Among Alameda County Residents Ever
Diagnosed with AIDS
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AIDS has been a reportable disease since the early 1980s, allowing examination of long-term trends in
death rates among the subset of people living with HIV ever diagnosed with AIDS. In 1985, there were
38.7 deaths (from any cause, whether HIV-related or not) per 100 Alameda County residents ever
diagnosed with AIDS. This rate dropped to 7.5 deaths per 100 by 1997 and has declined slowly but steadily
since then. In 2023, there were 58 deaths among the 3,705 residents living with AIDS for a rate of 1.5
deaths per 100 residents living with AIDS.
Figure 3.17: Death Rates by Year among Alameda County Residents Diagnosed
with AIDS, Alameda County, 1983-2023
Note: Death rates calculated among persons ever diagnosed with AIDS while a resident of Alameda County, regardless of county of residence at death. Deaths in PLHIV without AIDS are not reported here.
HIV in Alameda County, 2021-2023 30
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Figure 3.18: Deaths by Year among Alameda County Residents Diagnosed with
AIDS, Alameda County, 1983-2023
Figure 3.19: Death Rate among PLHIV by Year, Alameda County, 2006-2023
HIV in Alameda County, 2021-2023 31
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Figure 3.20: MPOX Cases by Coinfection with HIV, Alameda County, Year-end 2023
Figure 3.21: MPOX Cases with HIV Coinfection by Gender, Alameda County, Year-end 2023
In Alameda County, of the 254 diagnosed cases of MPOX by year-end 2023, almost 40% (97) were
among people living with HIV. Of those coinfected, all were assigned male at birth and 99% were
cisgender men.
HIV-MPOX Coinfection
MPOX, formerly known as Monkey Pox, is a communicable disease that can be spread through sexual con-
tact. Since 2022, it has been circulating within the United States. It can be prevented with two doses of a
vaccine and presents an acute danger to those who are immunocompromised such as people living with
HIV. For that reason, coinfection of MPOX and HIV is of public health importance and vaccination of the
community of people living with HIV is a priority for public health departments in areas where MPOX is
prevalent.
HIV in Alameda County, 2021-2023 32
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Figure 3.22: MPOX Cases with HIV Coinfection by Race/Ethnicity, Alameda County, Year-end 2023
Figure 3.23: MPOX Cases with HIV Coinfection by Age, Alameda County, Year-end 2023
Latinx residents made up a disproportionate number of coinfected cases relative to their proportion of
people living with HIV. Latinx residents were 42.3% of coinfected cases compared to 24.7% of people
living with HIV in 2023 whereas African Americans were 25.8% of coinfected cases and 36.8% of people
living with HIV. Over 68.1% of coinfected cases were between 30 and 49 years of age.
HIV in Alameda County, 2021-2023 33
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Figure 3.24: MPOX Cases with HIV Coinfection by Transmission, Alameda County, Year-end 2023
Among those with an MPOX and HIV coinfection, 95.9% were categorized as men who have sex with
other men or men who have sex with other men and who inject drugs at the time of their HIV diagnosis.
HIV in Alameda County, 2021-2023 34
Continuum of Care
Anti-retroviral therapy (ART), when taken regularly, can suppress HIV, preventing disease progression as
well as preventing the transmission of HIV entirely. Thus, ART benefits people living with HIV as well as
the larger community. To maximize these benefits, it is crucial that people living with HIV be diagnosed,
linked to and retained in regular HIV care. The prescription of antiretroviral treatment, adherence to
treatment and viral suppression is critical for prevention of HIV transmission. Together, these steps
comprise the continuum of HIV care or HIV care cascade: Linkage to care, retention in care, and viral
suppression.
The CDC’s Ending the HIV Epidemic (EHE) initiative aims to achieve 95% of people diagnosed with HIV
are linked to care and 95% of those linked to care are virally suppressed by 2025.4 Alameda County
previously reported linkage within 90 days; however, data on 30-day linkage is presented in this year’s report
to reflect timely linkage. This report defines linkage as a viral load or CD4 test conducted on or after the
date of diagnosis. Viral load and CD4 lab tests collected at the same time as diagnosis may not indicate
connection to a medical home for care and treatment, however, some organizations have rapid linkage
programs that connect patients to care on the same day as diagnosis. In this report, linkage percentages for
both definitions are reported, defined by if viral loads and CD4 tests on the date of diagnosis were included
or excluded.
Evaluation of care for people living with HIV is shown through two measures: engagement in care—
defined as at least one provider visit in a year, and retention—defined as two or more visits at least 90 days
apart.
In the United States, the CDC estimated that 81.6% of persons aged 13 year and over diagnosed from
January 2022 through September 2023 were linked to care within one month. Additionally, the CDC
estimated that among all people living with HIV aged 13 years and older diagnosed by 2021 and alive at year
-end 2022, 75.6% received any HIV care, 53.8% were retained in continuous care, and 65.1% were virally
suppressed.4
In California, 82.1% of those diagnosed in 2022 were estimated to have linked to care within one month.4
Among those living with diagnosed HIV in California, 73.7% were estimated to have received any HIV care
in 2022 and 64.7% were estimated to have been virally suppressed at the last test.5
This chapter examines the continuum of HIV care in Alameda County and select metrics for the Data to
Care program. Care outcomes are described by demographics such as race/ethnicity, age, sex at birth, and
gender.
HIV in Alameda County, 2021-2023 35
Figure 4.1: The Continuum of HIV Care among Newly Diagnosed 2021-2023 and People Living
with HIV in 2022, Alameda County
Notes: 1) Of 602 total new diagnoses, 4 died within 30 days and were excluded from analysis.
2) Of 6,192 PLHIV at year-end 2021, 101 were known to have died and an additional 425 to have moved out
of Alameda County in 2022 and were excluded from analysis.
The Overall Continuum of Care
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In Alameda County, 67.4% of new diagnoses between 2021 and 2023 were linked to care within 30 days if
HIV-related labs done on the date of diagnosis were excluded; 88.6% were linked to care if labs done on the
date of diagnosis were included. Approximately 46.6% of people living with HIV who resided in Alameda
County for the entirety of 2022 had two or more visits 90 or more days apart and were considered retained in
care. Viral suppression was estimated to be 68.6% that same year.
Linkage to Care
The following figures are the 30-day linkage to care estimates for Alameda County. Both estimates of linkage
to care are presented—one that includes labs done on the date of diagnosis and another that excludes them—
providing a range of what might be considered linked to care.
Overall, 88.6% of those diagnosed with HIV in Alameda County from 2021 to 2023 were linked to HIV care
within 30 days of their diagnosis. Excluding labs ordered on the date of diagnosis, 67.4% of newly diagnosed
cases were linked. Differences by sex were not statistically significant.
Excluding labs conducted on the same day as diagnosis, linkage was lowest among Latinx residents (60.2%)
and highest among White residents (75.0%). However, when including labs on the day of diagnosis, Latinx
had 90.2% linkage compared to Whites with 85.9%.
Among newly
diagnosed 2021-
2023
Among PLHIV Year-end 2022
HIV in Alameda County, 2021-2023 36
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Figure 4.2: Linkage to Care by Inclusion of Date of Diagnosis Lab, Alameda County, 2021-2023
Figure 4.3: Linkage to Care in 30 Days by Race/Ethnicity, Alameda County, 2021-2023
HIV in Alameda County, 2021-2023 37
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Figure 4.4: Linkage to Care in 30 Days by Age, Alameda County, 2021-2023
Note: "Sex" refers to sex assigned at birth.
Linkage was lowest among ages 25 to 29 years and highest among ages 13 to 19 years and greater than 49
years at 87.5% and 72.2%, respectively, although the youngest age group only contained 16 individuals.
Linkage was higher among people designated male at birth than female. By gender, linkage was lowest
among cis women at 66.3%.
Figure 4.5: Linkage to Care in 30 Days by Sex at Birth,
Alameda County, 2021-2023
Figure 4.6: Linkage to Care in 30 Days by Gender, Alameda
County, 2021-2023
HIV in Alameda County, 2021-2023 38
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Figure 4.7: Linkage to Care in 30 Days by Transmission Category, Alameda County, 2021-2023
Gay, bisexual and other men who have sex with men and persons who have an unknown transmission risk
had the lowest linkage of 66.1% and 64.2%. The highest percentages were among people who inject drugs
and men who have sex with other men and who inject drugs with 80.0% linkage, though both groups had
relatively few individuals.
Retention in Care
In 2022, 75% of people living with HIV were engaged in care, which is defined as one or more visits to an
HIV care provider as indicated by a new lab result. This differs from retention which requires two or more
HIV lab results at least 90 days apart in a calendar year. One limitation of these definitions is that some per-
sons may have had a provider visit without any laboratories drawn. People living with HIV that died or
moved in 2022 were excluded from all analyses of retention in care.
In 2022, 46.6% of people living with HIV were retained in care, i.e., had two or more labs 90 or more days
apart.
Percentages of retention in HIV care were highest among Asian/Pacific Islander (50.1%) and Latinx (47.5%)
people living with HIV in 2022. The lowest percentage was 45.4% of African American people living with
HIV retained in care.
People living with HIV aged 30 to 49 years at the end of 2022 had the lowest percentages of retention in
care; younger and successively older age groups had higher percentages of retention. Retention was highest
among those aged 13 to 19 years and 60 years and over; however, the number of people living with HIV
aged 13 to 19 years was small. People living with HIV designated male at birth had higher percentages of
retention than those designated female at birth. When stratifying by gender, transgender people living with
HIV had the highest retention percentages.
HIV in Alameda County, 2021-2023 39
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Figure 4.8: Engagement and Retention in Care by Race/Ethnicity, Alameda County, 2022
Figure 4.9: Engagement and Retention in Care by Age, Alameda County, 2022
HIV in Alameda County, 2021-2023 40
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Figure 4.10: Engagement and Retention in Care by Birth Sex, Alameda County, 2022
Figure 4.11: Engagement and Retention in Care by Gender, Alameda County, 2022
Note: "Sex" refers to sex assigned at birth.
HIV in Alameda County, 2021-2023 41
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Figure 4.12: Retention in Care by City/Place, Alameda County, 2022
The highest retention percentages were recorded in the county's northern region including Oakland,
Berkeley, Alameda, and Emeryville. It is worth noting that the number of people living with HIV in the
south county is much lower and therefore proportions are prone to larger shifts based on just a few
individuals. Within Oakland, the lowest retention percentages were in North Oakland, the Northwest Hills,
and the San Antonio neighborhoods.
HIV in Alameda County, 2021-2023 42
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Figure 4.13: Retention in Care by Region, Alameda County, 2022
Figure 4.14: Retention in Care by Oakland Neighborhood, Alameda County, 2022
HIV in Alameda County, 2021-2023 43
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Figure 4.15: Engagement and Retention by Nativity Status among PLHIV, Alameda County, 2022
Figure 4.16: Engagement and Retention by Region of Origin among PLHIV, Alameda County, 2022
Retention percentages were nearly equivalent between US-born and non-US-born people living with HIV.
Engagement was lower among non-US-born people living with HIV. Those born in Europe had the lowest
engagement and retention whereas those born in Asia had the highest.
HIV in Alameda County, 2021-2023 44
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Virologic Suppression
The final measure along the care continuum is virologic suppression, defined as a viral load under 200 cop-
ies/mL. For the purposes of these analyses, an undetectable viral load is defined as 75 copies/mL or less. A
person whose viral load is undetectable is also virally suppressed, but not everyone who is virally suppressed
has an undetectable viral load. People living with HIV that died or moved in 2022 were excluded. Disparities
in virologic suppression among people living with HIV in care can suggest possible differences in ART use or
access to care.
Approximately 68.6% of people living with HIV were virally suppressed at their most recent test in 2022,
with the majority being undetectable.
In 2022, 71.2% of White people living with HIV were virally suppressed. Viral suppression was 66.0% among
African Americans. Percentages of viral suppression by age mirrored the patterns of retention in care, ranging
from 61.2% among those ages 30 to 39 to 73.3% among those ages 60 and over. Viral suppression was high-
est among people assigned male at birth as well as cis men.
Figure 4.17: Viral Suppression by Race/Ethnicity, Alameda
County, 2022
Figure 4.18: Viral Loads by Race/Ethnicity, Alameda County,
2022
The “Suppressed” bar indicates a person who’s most recent VL lab in 2022
was between 75 and 200 copies/mL.
HIV in Alameda County, 2021-2023 45
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Figure 4.21: Viral Suppression by Birth Sex, Alameda County,
2022 Figure 4.22: Viral Suppression by Gender, Alameda County, 2022
Figure 4.19: Viral Suppression by Age, Alameda County, 2022 Figure 4.20: Viral Loads by Age, Alameda County, 2022
The “Suppressed” bar indicates a person who’s most recent VL lab in 2022
was between 75 and 200 copies/mL.
HIV in Alameda County, 2021-2023 46
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Figure 4.23: Percentage of PLHIV with Viral Suppression by City/Place, Alameda County, 2022
Within a city/place, the percent of persons living with HIV who had viral suppression were highest in
Fairview, San Lorenzo, Albany, Emeryville and Alameda and lowest in Dublin and South County. Dublin
houses Santa Rita Jail and is impacted by the unique traits of the incarcerated population there. In Oakland
the lowest percentages of persons with viral suppression were in West Oakland and Elmhurst.
HIV in Alameda County, 2021-2023 47
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Figure 4.24: Percentage of PLHIV with Viral Suppression by Region, Alameda County, 2022
Figure 4.25: Percentage of PLHIV with Viral Suppression by Oakland Neighborhood, Alameda County, 2022
HIV in Alameda County, 2021-2023 48
A Sankey diagram is useful for showing how people living with HIV progressed through the care continuum
and reached viral suppression. The width of each bar is proportional to the number of people living with
HIV represented by the identified outcome. Starting with all people living with HIV at year-end 2021, most
were still living in Alameda County at the end of 2022. A majority of people living with HIV in Alameda
County for all of 2022 were either engaged or retained in care during in 2022 (green) while some were
considered out of care (orange). The diagram shows the number of people living with HIV that were either
engaged or retained in care that were virally suppressed in 2022 (blue). Most people living with HIV
identified as virally unsuppressed were considered out of care, i.e., did not have a viral load or CD4 test in
2022. Only 14.3% of people living with HIV engaged in care and 5.1% of those retained in care were
unsuppressed.
Figure 4.26: Progression Through the Continuum of HIV Care Among PLHIV, Alameda County, 2022
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HIV in Alameda County, 2021-2023 49
Data Sources
All counts and proportions in this report were calculated using data from the Enhanced HIV/AIDS
Reporting System (eHARS). Numerators of rates were also obtained from eHARS; denominators were
derived using data from the United States Census6 (2020) and Esri (2012 and later). Mid-year population
estimates for intercensal years prior to 2012 as well as all year-end estimates were obtained through linear
interpolation. People living with HIV at the end of 2023 were identified from eHARS.
MPOX case data were extracted from the California Reportable Disease Information Exchange
(CalREDIE) data distribution portal.
Statistical Analysis
Significance Testing and Statistical Modeling
The statistical significance of associations between categorical variables was tested by Pearson's chi square
test or Fisher's exact test, as appropriate. Trend analyses were performed using Join Point7 to model crude
rates as a log-linear function of year separately for each stratum of the categorical variable(s); errors were
assumed to have Poisson variance and to be independent. Grid search and the modified Bayesian
Information Criterion were used to select the best fitting model from among those with zero to four join
points at least 2 years apart between 2007 and 2022 (the second and second-to-last years examined).
Data Suppression Rules
Rates
Rates for subpopulations with fewer than 12 cases are considered to be statistically unreliable and
were not presented. In these instances, the relative standard error of the rate exceeds 30%.
Death Ascertainment
Alameda County HIV surveillance officials are notified by the local Office of Vital Registration
whenever HIV is documented on a death certificate filed in Alameda County. Additionally, the
California Office of AIDS periodically matches state HIV registry data to national death databases
such as the National Death Index and the Social Security Administration’s Death Master File. People
living with HIV who died outside of Alameda County and were ever associated with Alameda
Appendix A
Technical Notes
HIV in Alameda County, 2021-2023 50
County or whose HIV was not documented on their death certificate are thus generally captured
through this process with some delay.
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The representativeness and accuracy of HIV surveillance data depend on the reliable, complete, and timely
reporting of data by health care providers and laboratories in accordance with California law.
Health Care Providers
Title 17, Section 2643.5, “HIV Reporting by Health Care Providers,” requires health care providers to
report cases of HIV disease (at any stage) to the local health department in the jurisdiction of their practice:
a) Each health care provider that orders a laboratory test used to identify HIV, a component of HIV, or
antibodies to or antigens of HIV shall submit to the laboratory performing the test a pre-printed
laboratory requisition form which includes all documentation as specified in 42 CFR 493.1105 (57 FR
7162, Feb. 28, 1992, as amended at 58 FR 5229, Jan. 19, 1993) and adopted in Business and Professions
Code, Section 1220.
b) The person authorized to order the laboratory test shall include the following when submitting
information to the laboratory:
1. Complete name of patient; and
2. Patient date of birth (2-digit month, 2-digit day, 4-digit year); and
3. Patient gender (male, female, transgender male-to-female, or transgender female-to-male); and
4. Date biological specimen was collected; and
5. Name, address, telephone number of the health care provider and the facility where services
were rendered, if different.
c) Each health care provider shall, within seven calendar days of receipt from a laboratory of a patient's
confirmed HIV test or determination by the health care provider of a patient's confirmed HIV test,
report the confirmed HIV test to the local Health Officer for the jurisdiction where the health care
provider facility is located. The report shall consist of a completed copy of the HIV/AIDS Case Report
form.
1. All reports containing personal information, including HIV/AIDS Case Reports, shall be sent
to the local Health Officer or his or her designee by:
A. courier service, US Postal Service Express or Registered mail, or other traceable mail;
or
B. person-to-person transfer with the local Health Officer or his or her designee.
2. The health care provider shall not submit reports containing personal information to the local
Health Officer or his or her designee by electronic facsimile transmission or by electronic mail
or by non-traceable mail.
d) HIV reporting by name to the local Health Officer, via submission of the HIV/AIDS Case Report,
shall not supplant the reporting requirements in Article 1 of this Subchapter when a patient's medical
Reporting Requirements
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HIV in Alameda County, 2021-2023 52
condition progresses from HIV infection to an Acquired Immunodeficiency Syndrome (AIDS)
diagnosis.
e) A health care provider who receives notification from an out-of-state laboratory of a confirmed HIV
test for a California patient shall report the findings to the local Health Officer for the jurisdiction
where the health care provider facility is located.
f) When a health care provider orders multiple HIV-related viral load tests for a patient or receives
multiple laboratory reports of a confirmed HIV test, the health care provider shall be required to submit
only one HIV/AIDS Case Report, per patient, to the local Health Officer.
g) Nothing in this Subchapter shall prohibit the local health department from assisting health care
providers to report HIV cases.
h) Information reported pursuant to this Article is acquired in confidence and shall not be disclosed by the
health care provider except as authorized by this Article, other state or federal law, or with the written
consent of the individual to whom the information pertains or the legal representative of that individual.
Note: Authority cited: Sections 120125, 120130, 120140, 121022, 131080 and 131200, Health and Safety
Code. Reference: Sections 1202.5, 1206, 1206.5, 1220, 1241, 1265 and 1281, Business and Professions Code;
and Sections 1603.1, 101160, 120175, 120250, 120775, 120885-120895, 120917, 120975, 120980, 121015,
121022, 121025, 121035, 121085, 131051, 131052, 131056 and 131080, Health and Safety Code.
Laboratories
Title 17, Section 2643.10, “HIV Reporting by Laboratories,” requires laboratories to report all HIV-related
laboratory tests to the local health department in the jurisdiction of the ordering provider:
a) The laboratory director or authorized designee shall, within seven calendar days of determining a
confirmed HIV test, report the confirmed HIV test to the Health Officer for the local health
jurisdiction where the health care provider facility is located. The report shall include the
1. Complete name of patient; and
2. Patient date of birth (2-digit month, 2-digit day, 4-digit year); and
3. Patient gender (male, female, transgender male-to-female, or transgender female-to-male); and
4. Name, address, and telephone number of the health care provider and the facility that
submitted the biological specimen to the laboratory, if different; and
5. Name, address, and telephone number of the laboratory; and
6. Laboratory report number as assigned by the laboratory; and
7. Laboratory results of the test performed; and
8. Date the biological specimen was tested in the laboratory; and
9. Laboratory Clinical Laboratory Improvement Amendments (CLIA) number.
b)
1. All reports containing personal information, including laboratory reports, shall be sent to the
local Health Officer or his or her designee by:
A. courier service, US Postal Service Express or Registered mail, or other traceable mail;
or
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B. person-to-person transfer with the local Health Officer or his or her designee.
2. The laboratory shall not submit reports containing personal information to the local Health
Officer or his or her designee by electronic facsimile transmission or by electronic mail or by
non-traceable mail.
c) A laboratory that receives incomplete patient data from a health care provider for a biological specimen
with a confirmed HIV test, shall contact the submitting health care provider to obtain the information
required pursuant to Section 2643.5(b)(1)-(5), prior to reporting the confirmed HIV test to the local
Health Officer.
d) If a laboratory transfers a biological specimen to another laboratory for testing, the laboratory that first
receives the biological specimen from the health care provider shall report confirmed HIV tests to the
local Health Officer.
e) Laboratories shall not submit reports to the local health department for confirmed HIV tests for
patients of an Alternative Testing Site or other anonymous HIV testing program, a blood bank, a
plasma center, or for participants of a blinded and/or unlinked seroprevalence study.
f) When a California laboratory receives a biological specimen for testing from an out-of-state laboratory
or health care provider, the California director of the laboratory shall ensure that a confirmed HIV test
is reported to the state health department in the state where the biological specimen originated.
g) When a California laboratory receives a report from an out of state laboratory that indicates evidence of
a confirmed HIV test for a California patient, the California laboratory shall notify the local Health
Officer and health care provider in the same manner as if the findings had been made by the California
laboratory.
h) Information reported pursuant to this Article is acquired in confidence and shall not be disclosed by the
laboratory except as authorized by this Article, other state or federal law, or with the written consent of
the individual to whom the information pertains or the legal representative of the individual.
Note: Authority cited: Section 1224, Business and Professions Code; and Sections 120125, 120130, 120140,
121022, 131080 and 131200, Health and Safety Code. Reference: Sections 1206, 1206.5, 1209, 1220, 1241,
1265, 1281 and 1288, Business and Professions Code; and Sections 101150, 120175, 120775, 120885-
120895, 120975, 120980, 121022, 121025, 121035, 131051, 131052, 131056 and 131080, Health and Safety
Code.
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California Code of Regulations (CCR) Title 17, Section 2643.5 requires all health care providers (HCP) to
report all cases of HIV disease they encounter in their clinical practice to the county/local health jurisdiction
in which the encounter occurs. Additionally, CCR Title 17, Section 2643.10 requires all commercial
laboratories to report all confirmed HIV tests they conduct to the local health jurisdiction of the HCP who
ordered the test, providing an additional means by which local health departments may learn of a case of
HIV disease.
In November 2015, California adopted the Electronic Laboratory Reporting (ELR) system for laboratories
performing HIV testing. HIV test results delivered through ELR meet the statutory and regulatory reporting
requirements for HIV test results. HIV-related laboratory results are submitted to the California
Department of Public Health (CDPH) and routed to Alameda County for investigation. Establishment of
ELR resulted in major changes in the local processing and management of laboratory results for HIV
surveillance. Reported labs are checked against a local database to identify cases not previously reported.
Potential new cases are investigated by trained field staff, who visit the office of the HCP that ordered the
laboratory test(s) or submitted the lab report and complete a case report using information abstracted from
the patient’s medical record and obtained from the HCP. For adult cases, standardized case report forms are
completed and submitted in CalREDIE—the secure CDPH system for electronic disease reporting and
surveillance. Hard copies of the Adult Case Report Form have largely been replaced by entry into
CalREDIE, but are sometimes used by HCPs to notify the local health jurisdiction. A copy of the Adult
Case Report form can be found here: https://acphd-web-media.s3-us-west-2.amazonaws.com/media/
communicable-disease/reporting-control/docs/adult-hivaids-casereportform.pdf.8 Hard copies of death
certificates and pediatric HIV cases documented on a paper case report form found here: http://
publichealth.lacounty.gov/dhsp/ReportCase/HIVAIDSCaseForm_CDC_Pediatric_Jan2019.pdf 9, are
mailed to the CDPH Office of AIDS. All case reports submitted to CDPH are routinely de-identified and
transmitted to CDC. When cases reported by different states appear to be the same person, CDC notifies
the appropriate states to contact each other directly and determine whether the cases are duplicates.
Security and Confidentiality of Data
In accordance with the county’s data use and disclosure agreement with CDPH, all data collected while
conducting HIV surveillance are used solely for public health purposes. Additionally, administrative,
technical, and physical safeguards are in place to ensure the security and confidentiality of these data. All
paper records are stored in locked file cabinets in an office with restricted access.
Surveillance in Alameda County
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HIV in Alameda County, 2021-2023 55
Limitations of Surveillance Data and of County Analysis
A major strength of HIV surveillance data is that it captures and reflects the entire population of HIV
diagnosed individuals. HIV surveillance data are not without their limitations however, which restrict the
analyses that can be done. These limitations include:
• Data quality: Public health investigators extract required information from medical records for HIV
reporting. Some information, such as risk factors or identification as transgender may not have been
available in the medical record, elicited from the patient by the HCP, or adequately described.
• Data quantity: In small subpopulations, the number of new diagnoses or people living with HIV was
not large enough to allow certain analyses. Statistical analyses based on small numbers may result in
unstable estimates which can be misleading.
• Timeliness of reporting: Surveillance data are the product of a long process triggered by a visit to a
HCP by an HIV-infected individual and culminating in the entry of case data into the statewide HIV
surveillance database at the California Department of Public Health. Intermediate steps include, but are
not limited to, laboratory testing, submission of case reports and lab results to the local health
department, and investigation of each report. Data preparation, analysis and interpretation take
additional time.
• History of reporting laws: The laws mandating the reporting of HIV-related laboratory test results and
of cases of HIV disease at its different stages have changed over time, and this impacts our ability to
characterize the epidemic at different points in the past. Although AIDS has been reportable since 1983,
HIV disease at its earlier stages was not reportable until mid-2002 and even then only by a non-name
code. More reliable, name-based data on HIV non-AIDS cases became mandated in 2006, and HIV-
related labs became reportable in California in 2009. Consequently, most of analyses are limited to 2006
and later, and analyses relying on laboratory reporting are limited to 2010 and later.
• Diagnosis date assigned to non-US-born cases: A small number of non-US-born people living with
HIV may have been initially diagnosed with HIV in another country before arriving in the US, but due
to the absence of verified information on date of initial diagnosis, their diagnosis date in the surveillance
data reflects the earliest date of HIV diagnosis in the US. As a consequence, new diagnoses and late
diagnoses may be overestimated in our data, especially among certain racial/ethnic groups.
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1. Centers for Disease Control and Prevention. Revised Surveillance Case Definition for HIV Infection --
United States, 2014, April 2014. URL http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm.
2. Eve Mokotoff, Lucia V. Torian, Monica Olkowski, James T. Murphy, Dena Bensen, Maree Kay Parisi,
and Jennifer Chase. Positions statements 2007: Heterosexual HIV transmission classification, 2007.
URL www.cste.org/resource/resmgr/PS/07-ID-09.pdf.
3. Centers for Disease Control and Prevention. Diagnoses, Deaths, and Prevalence of HIV in the United
States and 6 Territories and Freely Associated State, 2022. May 2024. URL http://www.cdc.gov/hiv-
data/nhss/hiv-diagnoses-deaths-prevalence.html.
4. Centers for Disease Control and Prevention. Core indicators for monitoring the Ending the HIV
Epidemic initiative: National HIV Surveillance System data reported through December 2023. May
2024. URL https://stacks.cdc.gov/view/cdc/156512.
5. California Department of Public Health. California HIV Surveillance Report – 2022. February 2024.
URL https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/California-
HIV-Surveillance-Report-2022.pdf.
6. U.S. Census Bureau (2020). American Community Survey 5-year estimates. Retrieved from https://
data.census.gov/cedsci/.
7. Joinpoint Regression Program, Version 4.6.0.0 - April 2018; Statistical Methodology and Applications
Branch, Surveillance Research Program, National Cancer Institute.
8. LA County Department of Public Health. Adult HIV/AIDS Case Report Form. May 2013. http://
www.publichealth.lacounty.gov/dhsp/ReportCase/AdultHIV-AIDSCaseReportForm.pdf
9. California Department of Public Health. Pediatric HIV/AIDS Confidential Case Report. January 2019.
http://publichealth.lacounty.gov/dhsp/ReportCase/
HIVAIDSCaseForm_CDC_Pediatric_Jan2019.pdf.
Bibliography
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Alameda County Public
Health Department
1100 San Leandro Blvd, 3rd Floor
San Leandro, CA 94577