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Dr. Kathleen Brady's 2013 Epidemiologic Update

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Dr. Kathleen Brady (AACO)'s epidemiologic update as presented to the Philadelphia Prevention Planning Group (PPG) on Wednesday, March 27, 2013.

Dr. Kathleen Brady (AACO)'s epidemiologic update as presented to the Philadelphia Prevention Planning Group (PPG) on Wednesday, March 27, 2013.

Published in Health & Medicine
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  • This paper was published in CID in March of 2011. The objective of this review was to describe and quantify the spectrum of engagement in HIV care.
  • Using data from the literature for each aspect of engagement in HIV care, Gardner estimated the spectrum of engagement in HIV care in the United States and the proportion of the HIV-infected population who have an HIV viral load <50 copies/mL.
  • They estimated that just 19% of the1.2 million persons infected with HIV in the United States had an undetectable viral load. These estimates are useful because they can be used to explore the potential impact of interventions to improve engagement in care on the proportion of HIV-infected individuals with an undetectable HIV viral load. Improvement in any single component in care will have minimal impact on the proportion of HIV-infected individuals in the US with an undetectable viral load. This occurs because achievement of an undetectable viral load is dependent on overcoming, sequential barriers, each of which has only a modest impact in overall engagement in care.
  • In the 46 states and 5 U.S. dependent areas with long-term confidential name-based HIV infection reporting, the estimated rate of diagnoses of HIV infection among adults and adolescents was 19.7 per 100,000 population in 2010. The rate for adults and adolescents diagnosed with HIV infection ranged from zero per 100,000 in American Samoa and the Northern Mariana Islands to 50.4 per 100,000 in the U.S. Virgin Islands.The following 46 states have had laws or regulations requiring confidential name-based HIV infection reporting since at least January 2007 (and reporting to CDC since at least June 2007): Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. The 5 U.S. dependent areas include American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting.
  • Estimated rates (per 100,000 population) of adults and adolescents living with a diagnosis of HIV infection at the end of 2009 in the 46 states and 5 U.S. dependent areas with long-term confidential name-based HIV infection reporting are shown in this slide. Areas with the highest estimated rates of persons living with a diagnosis of HIV infection at the end of 2009 were New York (795.9), the U.S. Virgin Islands (632.7), Florida (594.8), Puerto Rico (555.7), New Jersey (497.1), Georgia (442.6) and Louisiana (440.4).  The following 46 states have had laws or regulations requiring confidential name-based HIV infection reporting since at least January 2007 (and reporting to CDC since at least June 2007): Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming. The 5 U.S. dependent areas include American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data are estimates. Estimated numbers resulted from statistical adjustment that accounted for reporting delays, but not for incomplete reporting. Persons living with a diagnosis of HIV infection are classified as adult or adolescent based on age at end of 2009.

Transcript

  • 1. The HIV Engagement in Care Cascade KATHLEEN A. BRADY, MD MEDICAL DIRECTOR/MEDICAL EPIDEMIOLOGIST AIDS ACTIVITIES COORDINATING OFFICE MARCH 27, 2013
  • 2. The Gardner Cascade
  • 3. Engagement in Care
  • 4. Gardner Stage of Engagement in HIV Care
  • 5. Gardner Stage of Engagement in HIV Care 19% undetectable
  • 6. National and Local Engagement in Care Data  National and local HIV Surveillance System  Prevalence (total, diagnosed) – number of persons living with HIV  Linkage to care  Medical Monitoring Project (MMP)  Retention in care  Prescribed ART  Viral suppression
  • 7. Methods Prevalence  HIV diagnosis data  Data adjustments at the national level  Back-calculation methods to estimate unaware Linkage to Care  Data reported through December 2011  Percentage of persons with >1 CD4 or viral load test result within 3 months of HIV diagnosis
  • 8. Medical Monitoring Project MMP is a national probability sample of HIV-infected persons receiving care in the US in order to:  describe HIV care and support services being received and the quality of such services  describe the prevalence and occurrence of co-morbidities related to HIV disease  determine prevalence of ongoing risk behaviors and access to and use of prevention services among persons living with HIV  identify met and unmet needs for HIV care and prevention services in order to inform community and care planning groups, health care providers and other stakeholders Philadelphia has participated in MMP since 2005. All charts of sampled patients are abstracted for clinical information and patients are offered a voluntary interview.
  • 9. MMP Population Size Estimates States, facilities, and patients sampled with known probabilities Analysis weights include:  Design weights  Inverse of the probability of selection  Extend inference from sample to reference population Non-response adjustment  Extend inference from respondents to sample Sum of weights estimates number of HIV-infected adults who received at least one medical visit January-April 2009
  • 10. MMP Definitions Retention in care: Number of HIV-infected adults who received at least one medical care visit between January and April 2009 Prescription of antiretroviral therapy (ART): Documentation in medical record abstraction of any ART prescription in the past 12 months Viral suppression: Documentation in medical record abstraction of most
  • 11. Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • 12. For every 100 people living with HIV:US PhiladelphiaNumber Number Are aware of their Are aware of their82 82 infection infection66 Are linked to HIV care 62 Are linked to HIV care37 Stay in HIV care 52 Stay in HIV care Get antiretroviral Get antiretroviral33 46 therapy therapy Have a very low amount Have a very low amount25 30 of virus in their body of virus in their body 2009 Data
  • 13. Who is Aware?
  • 14. Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • 15. HIV Prevalence in Philadelphia (reported thru 6/30/2012) 19,157 PLWHA (aware)  Rates (known) vary by  11,583 AIDS cases race  7,574 HIV cases  2.1% of blacks 4,205 estimated to be  1.5% of Latinos living with HIV and  0.7% of whites unaware  Rates vary by sex 1.59% Philadelphia  1.9% of males residents estimated to be  0.7% of females HIV+
  • 16. HIV Prevalence in Philadelphia EMA (reported thru 6/30/2012) 25,968 PLWHA (aware)  Rates (known) vary by  15,178 AIDS cases race  10,790 HIV cases  1.4% of blacks 5,700 estimated to be  0.9% of Latinos living with HIV and  0.2% of whites unaware  Rates vary by sex 0.5% Philadelphia EMA  0.7% of males residents estimated to be  0.3% of females HIV+
  • 17. HIV/AIDS Cases by Date of Diagnosis AIDS HIV 1400 1308 1302 1178 1177 1200 1200 1001Number of Cases 898 894 895 907 861 940 918 921 893 1000 821 712 756 729 712 800 652 600 452 400 221 239 176 200 0 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 20 20 20 Year 20
  • 18. HIV/AIDS Cases by Sex and Date of Diagnosis AIDS Female AIDS Male HIV Female HIV Male 1600 1400Number of Cases 1200 1000 800 600 400 200 0 91 93 95 97 99 01 03 05 07 09 11 19 19 19 19 19 20 20 20 20 20 20 Year 21
  • 19. HIV Cases by Race/Ethnicity and Date of Diagnosis White AfrAm Hispanic 700 575 594 600 534 498 Number of Cases 479 500 400 300 171 200 142 127 210 106 110 100 133 146 127 95 0 2006 2007 2008 2009 2010 2011 Year 22
  • 20. HIV diagnoses by risk group, 2007-2011600500400300200100 0 2007 2008 2009 2010 2011 MSM IDU HET
  • 21. Demographics of new positives, MSMNew HIV diagnoses among New HIV diagnoses amongMSM by race, 2007-2011 MSM by age, 2007-201170% 60%60% 50%50% 40%40% 30%30%20% 20%10% 10% 0% 0% Black Latino White 13 - 24 25 - 44 45+
  • 22. Demographics of new positives, MSM youthNew HIV diagnoses among New HIV diagnoses amongMSM youth, 2007-2011 MSM youth, 2007-2011 Race Age 7.6% 12.6% 9.3% 75.4% 92.0% Black White Latino 13-17 18-24
  • 23. Demographics of new positives, IDUNew HIV diagnoses among New HIV diagnoses amongIDU, 2007-2011 IDU, 2007-2011 Race Age 10.2% 16.0% 44.1% 36.2% 38.0% 53.1% Black White Latino 13-24 25-44 45+
  • 24. Demographics of new positives, IDU 2007 - 2011 Sex 29.8% Male Female 70.1%
  • 25. Demographics of new positives, HeterosexualsNew HIV diagnoses among New HIV diagnoses amongHET, 2007-2011 HET, 2007-2011 Race Age 8.8% 3.8% 15.0% 34.6% 50.6% 72.7% Black White Latino 13-24 25-44 45+
  • 26. Demographics of new positives, HET 2007 - 2011 Sex Male 49.2% Female 50.7%
  • 27. Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMA EMA Philadelphia PA NJ Total EMA N=1,606 N=378 N=237 N=2,221 % % % %Race/EthnicityWhite, non-Hispanic 481 21.7 16.1 38.9 32.1Black, non-Hispanic 1,313 59.1 64.1 46.8 45.1Hispanic 372 16.7 17.8 10.0 20.3Asian/PI 3 0.2 1.2 2.4 2.1American Indian/Alaskan 4 0.2 0.0Native 1.5 0.0Multi-Race 18 0.8 0.6 1.9 0.4Unknown 0 0.0 0.0 0.0 0.0GenderMale 1,634 73.6 73.6 74.6 71.7Female 587 26.4 26.4 25.4 28.3
  • 28. Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMA EMA Philadelphia PA NJ Total EMA N=1,606 N=378 N=237 N=2,221 % % % %Age <13 years 13 0.6 .5 0.8 0.8 13 - 19 years 140 6.3 6.4 7.4 3.8 20 - 44 years 1,51 69.8 70.5 6.9 69.6 45+ years 517 23.3 22.5 24.9 25.7Mode of TransmissionMen who have sex with men 840 37.8 39.5 29.9 38.8Injection drug users 222 10.0 9.5 14.6 6.3Men who have sex with men 50 2.3 2.2 2.9 1.3and inject drugsHeterosexuals 813 36.6 35.4 36.0 46.0Other/Hemophilia/blood 0 0.0 0.0 0.0 0.0transfusionPerinatal Exposure 18 0.8 0.6 1.9 0.8Risk not reported or identified 192 8.6 9.5 10.1 0.8
  • 29. Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMA EMA Philadelphia PA NJ Total EMA N=1,606 N=378 N=237 N=2,221 % % % %InsuranceMedicaid 411 18.5 23.1 0.0 16.9Private 414 18.6 21.9 0.0 26.6No Coverage 167 7.5 7.7 0.0 18.1Other Public Funding 305 13.7 18.4 0.0 3.8Unknown 924 41.6 28.9 100.0 34.6
  • 30. Summary High HIV morbidity in Philadelphia, less so in the EMA Philadelphia epidemic predominantly affects minority populations MSM and Heterosexual transmission predominant modes of transmission Cases among MSM are increasing Growing numbers of persons living with HIV and AIDS 25% decline in newly diagnosed AIDS 39
  • 31. Who is unaware?
  • 32. Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • 33. Concurrent HIV/AIDS, 2010
  • 34. Concurrent HIV/AIDS, 2010
  • 35. Linkage to care
  • 36. Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • 37. Linkage to Care 2009-2010 by Age, Race85% 81%80% 79% 76% 76% 75%75% 74% 73% 72%70% 68%65%60% Total 13-24 25-34 35-44 45-54 55+ Black Hispanic White
  • 38. Linkage to Care 2009-2010 by Sex, Mode90% 81%80% 75% 74% 73% 74% 72% 68% 69%70%60%50% 43%40%30%20%10%0% Total Male Female MSM Male IDU Male HET Male Female IDU Female HET MSM/IDU
  • 39. Retention in care
  • 40. Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • 41. Definition: Met Need for Primary Care Met Need for Primary Care defined as measurement of at least one CD4 count and/or one Viral Load and/or receipt of antiretroviral therapy during a specified time period
  • 42. Framework Input  Population sizes of those with HIV and AIDS within the service area  Care Patterns of those with HIV and AIDS Calculated Result  Number of persons with HIV and AIDS with unmet need
  • 43. Population Sizes Population Sizes Value Data Source(s)Row A. Number of persons living 11,569 Local eHARS data with AIDS (PLWA), for (15,178) (EMA data) the period of 12/31/2011Row B. Number of persons living 7,523 Local eHARS data with HIV (PLWH)/non- (10,090) (EMA data) AIDS/aware, for the period of 12/31/2011Row C. Total number of 19,092 Local eHARS data HIV+/aware for the (25,968) (EMA data) period of 12/31/2011
  • 44. Care Patterns Value Data Source(s)Row D. Number of PLWA 9,948 Surveillance Data who received the (13,053) (Lab Data), specified HIV CAREWare primary medical (EMA data) care during the 12-month period of 2011Row E. Number of 5,132 Surveillance Data PLWH/non-AIDS (7,370) (Lab Data) who received the CAREWare (EMA data) specified HIV primary medical care during the 12-month period of 2011
  • 45. Row F. Total number of 15,080 HIV+/aware who (20,423) received the specified HIV primary medical care during the 12- month period of 2011
  • 46. Calculated Results Value CalculationRow G. Number of PLWA who 1,621 =A–D did not receive primary (2,125) (EMA data) medical services during (14.0%) the 12-month period of 2011Row H. Number of PLWH/non- 2,391 =B–E AIDS who did not receive (3,420) (EMA data) primary medical services (31.8%) during the 12-month period of 2011Row I. Total of HIV+/aware not 4,012 =G+H receiving specified (5,545) (EMA data) primary medical care (21.0%) services (quantified estimate of unmet need
  • 47. Unmet need by demographic groups, 201140.0% 40.0%35.0% 35.0% 33.4% 31.8% 33.6%30.0% 27.4% 30.0% 28.1%25.0% 25.0%20.0% 20.0% 15.5% 15.2%15.0% 15.0% 15.2% 10.6%10.0% 13.4% 10.0% 5.0% 5.0%0.0% 0.0% HIV AIDS HIV AIDS Black White Hispanic Male Female
  • 48. Unmet need by insurance status, 201150.0% 46.4%45.0% 43.1%40.0%35.0% 33.7% 28.3% 29.6%30.0% 26.6%25.0% 22.4%20.0%15.0% 13.5%12.6%10.0% 7.5% 5.0% 0.0% HIV AIDS Medicaid Private Other public Unknown None
  • 49. Disparities
  • 50. Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • 51. Engagement in Care by Sex, 2009 Male Female12000 82% 600010000 5000 82%8000 4000 67% 47% 54% 43%6000 3000 35% 35%4000 20002000 1000 0 0
  • 52. Engagement in Care by Race/Ethnicity, 200912000 82%100008000 49%6000 42% 31%4000 82% 54%50%45% 82%68%2000 60% 39% 0 Black White Hispanic Diagnosed In Care On ART Suppressed
  • 53. Engagement in Care by Mode of Transmission, 20096000 82% 82%5000 46684000 64% 49% 46% 48% 51%3000 39% 43% 32% 33%20001000 0 MSM HET male HET female Diagnosed In Care On ART Suppressed
  • 54. Engagement in Care by Age Group, 2009600050004000300020001000 0 18-24 25-34 35-44 45-54 55+ Diagnosed In Care On ART Suppressed
  • 55. Engagement in Care Summary On ART  Higher for males than females  Higher for men who have sex with men (MSM) than for women who have sex with men (WSM) Viral suppression  Higher for males than females  Higher for MSM than WSM  Higher for whites compared to blacks and Hispanics  Higher for those >50 compared to 18-29 year olds All P values <0.05
  • 56. Starting Antiretroviral Therapy in 2012: A Compendium of Interactive Cases clinicaloptions.com/hiv What Will It Take to Substantially Reduce HIV Transmission in an Entire Population? Undiagnosed HIV •1,200,000 Not linked to care Not retained in care•Number of Individuals •1,000,000 ART not required ART not utilized •800,000 Viremic on ART Undetectable •600,000 HIV-1 RNA •400,000 •66% •200,000 •34% •28% •19% •22% •21% •0 •Current •DX •Engage •Treat •VL < 50 •Dx, 90% 90% 90% in 90% Engage, Tx, and VL < 50 in 90% •Answer: Treatment AND Prevention •Gardner EM, et al. Clin Infect Dis. 2011;52:793-800.
  • 57. The EndQUESTIONS?