Uses of Strategic Information to Assess Health Equity Tiffany LaDanaWest, MPH, MSPH Bureau Chief, Strategic Information Bureau District of Columbia, Department of Health
Health Inequities in US Gender, Race and Socioeconomic Factors that drive health inequities in US Heavily Influence by Environment Disease Syndemics Access to Prevention, Care and Treatment Services Influence Individual Behavior Risk Behaviors in social and sexual networks Health Seeking Behavior Utilization of Prevention, Care and Treatment Services Triangulate Syndemic, Behavioral, Service to assess Health Inequities to target policies and programs populations at greatest need Greater Focus on Health Outcomes where inequities exist
Cumulative and Annual Diagnosed Number ofAIDS Cases, By Race/Ethnicity and Year, UnitedStates, 1989-2008 Cumulative_v_Dx_with_trails_wmv.wmv
Cumulative and Annual Diagnosed Number ofAIDS Cases, By Transmission Category and Year,United States, 1989-2008 MOT_no_total_wmv.wmv
Annually Diagnosed AIDS Cases, by Sex andYear, United States, 1989-2008
Percent Below the Federal Poverty Line, ByRace/Ethnicity and Year, United States, 1989-2008
HIV Infection Among Heterosexuals in Urban Areas, by Socio-Economic Indicators, 2006-2007, N=14,837 National HIV Behavioral Surveillance (NHBS) Heterosexuals at High Risk for HIV Areas of High Rates of HIV/AIDS and Poverty Approximately 2.0% HIV Prevalence 2.1% Women and 1.9% Men 4.2% 40-50 year olds, 2.2% 30-39 year olds, 0.6%, 18-29 year olds 3.1% Northeast, 2.7% South, Midwest, South, Territories <1%*CDC. Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence --- 24 Cities,United States, 2006--2007. MMWR 2011;60:1045-1049.
HIV Infection Among Heterosexuals in Urban Areas, by Socio-Economic Indicators, 2006-2007, N=14,837-Structural/Environmental 3.5% 3.0% 2.5%HIV Prevalence 2.0% 1.5% 1.0% 0.5% 0.0% *CDC. Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence --- 24 Cities, United States, 2006--2007. MMWR 2011;60:1045-1049.
HIV Infection Among Heterosexuals in Urban Areas, by HIV Risk Factor, 2006-2007, N=14,837-Behavioral 5.0% 4.5% 4.0% 3.5% 3.0%HIV Prevalence 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Used crack cocaine Did not Exchanged sex for Did not Received an STD Had not money or drugs diagnosis *CDC. Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence --- 24 Cities, United States, 2006--2007. MMWR 2011;60:1045-1049.
Estimated Number of New HIV Infections amongMen who have Sex with Men, By Age Estimated Number of New HIV Infections among Men who have Sex with Men (MSM), 2009, By Race/Ethnicity and Age * Estimates of New HIV Infections in the United States, 2006–2009, The Center for Disease Control and Prevention Fact Sheet, August 2011
Estimated Number of New HIV Infections amongMen who have Sex with Men, By Race Estimated Number of New HIV Infections among Men who have Sex with Men (MSM), Ages 13-29, 2006-2009, By Race/Ethnicity and Age * Estimates of New HIV Infections in the United States, 2006–2009, The Center for Disease Control and Prevention Fact Sheet, August 2011
Overview: HIV/AIDS in District of Columbia Prevalence of HIV/AIDS in the District of Columbia, 2009 • 16,721 reported living with HIV/AIDS in the District at the end of 2009 • 5,505 new HIV cases reported between 2005 and 2009 • 3.2% of the District’s population diagnosed with HIV/AIDS • one-third to one-half of people (locally) may be unaware of their HIV status. (Source: DC NHBS data)DC Resident Living with HIV/AIDS as of 2009, by Gender andRace/Ethnicity Black Hispanic White Other TotalMale 8,325 756 2,620 350 12,051Female 4,256 156 141 117 4,670Total 12,581 912 2,761 467 16,721 14DC% 75.2% 5.5% 16.5% 2.8% 100.0%US% (2008) 49.3% 20.0% 27.8% 2.9% 100.0%
HIV Prevalence among High Risk Population, District of Columbia HIV Prevalence by Sex HIV Prevalence among Study Populations8.0% and Race/Ethnicity 25.0% 25.0% 7.1%7.0%6.0% 20.0%5.0% 4.7% 15.0%4.0% 13.0% 3.4% 2.9% 2.8%3.0% 10.0% 2.1% 7.7%2.0% 1.8% 6.3% 5.0% 3.9%1.0%0.0% Black All Blacks Hispanic White Black All All Whites 0.0% Males Males Males Females Hispanics Black MSM White MSM IDU Male Female Heterosexuals Hterosexuals
Syndemics and Service Delivery High rates of STDs among Approximately 91% Health youth Care Coverage High rates of Syphilis, Generous prevention, care chronic Hepatitis B and and treatment programs HIV among MSM and High No ADAP Waiting List rates of co-infection Extensive ADAP formulary High rates of chronic Generous coverage on local Hepatitis C among IDU public health insurance and Heterosexuals programs Sub-optimal health Poor Healthcare Utlization outcomes
Mean Community Viral Load among Whitesand Blacks Living with HIV/AIDS in DC, 2008 50,000Mean Community Viral Load (copies/mL) 45,000 40,000 39,173 35,000 30,000 25,000 20,000 18,283 15,000 10,000 5,000 0 White Black N=762 N=3,395
Linkage to Care among Newly Diagnosed Cases in DC, by Race/Ethnicity, 2005-2009 80.0% 70.0% Proportion entering care 60.0% 50.0% 40.0% White Black 30.0% 20.0% 10.0% 0.0% < 3 months 3-6 months 6-12 months > 1 year*Entry into care was determine by the date of the first CD4 count or percentage test or viral loadtest reported to the DCDOH.
Retention in Care and Not in Care among NewlyDiagnosed Cases in DC, by Race/Ethnicity 2005-2009 18% 16% 14% 12% 10% Retained in care 8% No care 6% 4% 2% 0% White Black Not in care: absence of any HIV-related laboratory tests indicative of receipt of HIV primary care within the study period •Continuously in care (retained in care): presence of at least 2 HIV-related laboratory tests within 12 months of the initial linkage laboratory test date, each 10 to 14 weeks apart (modified HRSA definition)
National HIV Behavioral Surveillance Project(NHBS) Men who have Sex with Men, 2008 Unprotected Receptive Anal Intercourse, Unprotected Insertive Anal Intercourse, By Race, N=422 By Race, N=422 60.0% 60.0% 56.7% 51.0% 50.0% 50.0% 40.0% 40.0% 30.0% 30.0% 29.0% 25.3% 20.0% 20.0% 10.0% 10.0% 0.0% 0.0% White MSM Black MSM White MSM Black MSM
National HIV Behavioral Surveillance Project(NHBS) Men who Have Sex with Men, 2008 HIV Prevalence among Study Participants, 30.0% by Race, N=422 26.0% 25.0% 20.0% 15.0% 10.0% 7.9% 5.0% 0.0% White MSM Black MSM
Mean Community Viral Load among Whiteand Black MSM with HIV/AIDS in DC, 2008 45,000 Mean Community Viral Load (copies/mL) 40,000 35,000 31,404 30,000 25,000 20,000 19,732 15,000 10,000 5,000 0 White MSM Black MSM N=645 N=901
Linkage to Care among Newly Diagnosed White and Black MSM in DC, 2005-2009 80.0% 70.0% 60.0% 50.0% 40.0% White MSM 30.0% Black MSM 20.0% 10.0% 0.0% < 3 months 3-6 months 6-12 months > 1 year Pearson’s Chi-square p value, p=0.0006Linkage to care was determine by the date of the first CD4 count or percentage test or viral loadtest reported to the DCDOH.
Retention in HIV Care among Newly Diagnosed White and Black MSM in DC, 2005-2009 90.0% 80.0% Proportion of MSM Cases 70.0% 60.0% 50.0% White MSM 40.0% Black MSM 30.0% 20.0% 10.0% 0.0% Retained in Care Sporadic Care No Care Pearson’s Chi-square p-value, p=0.0020Continuous care is defined as having evidence (e.g. HIV-related lab test) of at least 2 visits to an HIV medicalprovider 10-14 weeks apart. Sporadic care is defined as having only one visit to a provider or 2 visits but morethan 14 weeks apart.
Targeted Services Finding ActionGeneral Populations • High burden of disease (HIV, STD, Hep • Opt out routine screening in C) emergency departments • Routine GC/CT screening in women and girls of childbearing age • Health Behavior and Risk Reduction • Municipal Condom Distribution: online, venues, schools • Increased HIV/STD partner servicesMSM • Co morbidities: HIV/Syphilis • Engage w/providers who serve MSM • High Rates HIV • Encourage routine HIV and syphilis • High rates of high risk behaviors screening • Bi-Annual HIV and STD testing • Messages developed to reduce stigma • Increase HIV/STD partner services • Hepatitis A/B Screening/VaccinationHeterosexuals • High rates HIV, STDs • (General Population Strategies) • High rates of high risk behaviors • Social Marketing/harm Reduction • Low risk perception • Integrated Partner Services (PCRS) 29
Geographic Distribution of Substance Abuse Needle ExchangePrograms Overlay - Heroin Arrests in the District of Columbia, 2008 Heroin Arrests Substance Abuse Needle Exchange Programs
Involvement in the HIV response Medical Fed Gov: $$$, Establishment: TA, Guidelines Media: info, services, pops Dir ads Families, Social Networks, DC GOVT Individuals:change Leadership, Academia: TA, Coordination, Research, Services NGOs, CBOs: $$$ program, pops DC Planning FBOs: Councils: leaders, Priorities, $ stigma, direction/advice •Priorities support, •Experiences & Approaches services •Reality & Implementation •Best Practices Private/Business •Gaps in Service, Effect and insurance, social resp Intention prevention •Cost-efficiency, Resources EVENTUAL IMPACT Preview
Conclusions: Health Inequalities are associated with both environmental and social and sexual networks Role of Public Health System is to ensure targeted, evidence scalable strategies that influence positive health outcomes Targeted, Integrated Messages and Service Delivery Monitoring Evaluation of Health Outcomes to influence Change
Special Thank You ONAP-LA Mario Perez George Washington University School of Public Health Alan Greenberg, Amanda Castel, Manya Magnus, Irene Kuo Emory University CFAR Patrick Sullivan, Jeb Jones HAHSTA-DC Angelique Griffin, Jen Opoku, Sarah Willis, Rowena Samala CDC Irene Hall, Amy Lansky Dad, Mom, Tony-For Believing in Me