The HIV Engagement in Care Cascade by Dr. Kathleen Brady
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The HIV Engagement in Care Cascade by Dr. Kathleen Brady

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Dr. Kathleen Brady of Philadelphia's AIDS Activities Coordinating Office (AACO) gave this presentation at the January 9, 2013 Comprehensive Planning Committee meeting.

Dr. Kathleen Brady of Philadelphia's AIDS Activities Coordinating Office (AACO) gave this presentation at the January 9, 2013 Comprehensive Planning Committee meeting.

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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.
  • STARHS = serologic testing algorithm for recent HIV seroconversion
  • As with national data, the data indicates that Philadelphia has a generalized epidemic in the heterosexual community and nearly meets the definition of a concentrated epidemic (HIV prevalence rate is 5% in at least one high-risk subpopulation)
  • As with national data, the data indicates that Philadelphia has a generalized epidemic in the heterosexual community and nearly meets the definition of a concentrated epidemic (HIV prevalence rate is 5% in at least one high-risk subpopulation)
  • As with national data, the data indicates that Philadelphia has a generalized epidemic in the heterosexual community and nearly meets the definition of a concentrated epidemic (HIV prevalence rate is 5% in at least one high-risk subpopulation)

The HIV Engagement in Care Cascade by Dr. Kathleen Brady The HIV Engagement in Care Cascade by Dr. Kathleen Brady Presentation Transcript

  • The HIV Engagement in Care Cascade KATHLEEN A. BRADY, MD MEDICAL DIRECTOR/MEDICAL EPIDEMIOLOGIST AIDS ACTIVITIES COORDINATING OFFICE JANUARY 9, 2013
  • The Gardner Cascade
  • Engagement in Care
  • Gardner Stage of Engagement in HIV Care
  • Gardner Stage of Engagement in HIV Care 19% undetectable
  • 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
  • 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
  • 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.
  • 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
  • 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
  • Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • 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
  • Who is Aware?
  • Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • 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 5,092 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+
  • 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 19
  • 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 20
  • 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 21
  • HIV diagnoses by risk group, 2007-2011600500400300200100 0 2007 2008 2009 2010 2011 MSM IDU HET
  • 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+
  • 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
  • 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+
  • Demographics of new positives, IDU 2007 - 2011 Sex 0 29.8% Male Female 70.1%
  • 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+
  • Demographics of new positives, HET 2007 - 2011 Sex 0 Male 49.2% Female 50.7%
  • Summary High HIV morbidity in Philadelphia 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 35
  • Who is getting infected?
  • Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • Incidence Surveillance Collect and STARHS test the diagnostic blood specimens from all newly diagnosed HIV infections reported from public and private laboratories and providers to HIV Surveillance Unit. Collect the HIV testing information needed for the statistical estimates of incidence. Calculate population-based estimates of HIV incidence. Use these estimates to identify emerging sub- epidemics, monitor trends, target prevention resources and interventions to areas and populations most heavily affected, and evaluate programs.
  • Incidence vs. Prevalence 1981 2006 2007HIV Incidence = the number of individuals newly infected with HIV within a given period of time (6 - 12 months). 1981 2006 2007HIV Prevalence = the total number of HIV cases that exist at a specific time within a specific population.
  • What is STARHS? Serologic Testing Algorithm for Recent HIV Seroconversion
  • Requirements for HIV Incidence SurveillanceRemnant HIV+ Supplemental DataSerum Includes: •Race, sex, mode of STARHS transmission Testing •Testing history & using BED reasons for testing (Calculating weights) Assay •Any exclusionary info (AIDS diagnosis, prior recent ART) •Adjust for LFU, QNS HIV Incidence Estimation
  • CDC STARHS Test Results (+) standard test and (+) STARHS test = long-standing HIV infection (+) standard test and (-) STARHS test = recent HIV infection
  • National Incidence Data, 2010 Estimated 47,500 HIV infections in 2009 in adults and adolescents (95% CI, 42,000 – 53,000)  Estimated incidence 18.8 infections per 100,000 population  44% among blacks, 21% Latinos  63% among MSM, 25% heterosexual  26% among 13-24 year olds Early signs of an encouraging decrease in new HIV infections among black women  21 percent decrease between 2008 and 2010 Continuing increase in new infections among young gay and bisexual men  22 percent increase between 2008 and 2010
  • 2010 Local Estimate of HIV Incidence Local estimate of 577 new HIV infections in 2010 in adults and adolescents (95% CI, 385-769)  2010 estimate is significantly lower than the estimate from 2008 (926 infections) and 2009 (945 infections) Case rate of 45.1 infections per 100,000 population (2.4 times that of the national rate) The estimated decline in incidence must be interpreted with caution due to violations in the estimation assumptions
  • HIV Incidence Trends by Demographic Groups 1000 800 Total 600 Age 13-24 400 Male 200 Black MSM 0 2006 2007 2008 2009 2010
  • HIV Incidence Trends by Demographic Groups 1000 800 Total 600 Age 13-24 400 Male 200 Black 0 MSM 2006 2010
  • Estimated Incidence Rates - 2010 Population Population in Incidence Estimated 95% CI 95% CI 2010 (13 +) Estimate, Case Rate lower upper ESTIMATED 20010 per bound bound 100,000 MSM 29,737 306 1,029.0 578.4 1,483.0 IDU 37,378 44 117.7 0.0 254.2 HET 294,682 226 76.7 30.1 60.1 *Includes persons >13 living in povertyData Source: PDPH/AACO HIV Incidence Surveillance Program
  • Incidence Summary Includes people unaware of their status.  40% decrease between 2009 and 2010  P<0.05 Declines in all demographic groups Incidence higher than baseline 2006 data for MSM and youth 13-24
  • Who is unaware?
  • Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • Concurrent HIV/AIDS, 2010
  • Concurrent HIV/AIDS, 2010
  • National HIV Behavioral Surveillance Risk Behaviors  Assess prevalence of and trends in risk behaviors  Sexual risk behaviors  Drug-use risk behaviors HIV Testing Behaviors  Assess prevalence of and trends in HIV testing behaviors (not included until HET-1)
  • NHBS Objectives (cont.) Prevention  Assess exposure to and use of prevention services  Assess impact of prevention services on behavior  Identify prevention service gaps and missed opportunities for prevention
  • NHBS-MSM3 Interviews conducted at venues where at least 50% of men identified as MSM  List of venues included in your attachments 566 MSM interviewed in Philadelphia  545 had sex with a man in the last 12 months  26.2% white, 57.6% black, 11.4% Latino  83.6% identified as gay, 14.6% bisexual, 1.9% as straight
  • NHBS-MSM Summary We are not currently meeting the PHS guidelines for HIV testing  76.8% of MSM ever tested  Less than half (46.9%) of MSM had tested in the last year Lower prevalence of HIV in MSM seen in Philadelphia
  • Philadelphia NHBS-MSM3, 2011 Demograp MSM3 MSM3 hic Group % HIV % New% of MSM who had an Positive PositivHIV test in the last 12 Tested = es 519 months 78.5% Total 11.9% 29.0% Race76.4% 76.2% 76.1% Black 14.9% 31.8% White 8.5% 16.7% Latino 6.8% 50.0% NHBS-MSM3 Age ALL MSM Black MSM 18-24 8.2% 50.0% Latino MSM White MSM 25-44 10.6% 35.1% 45+ 19.8% 21.1%
  • NHBS-IDU2 539 IDU interviewed in Philadelphia  75.3% male, 24.7% female, 88.1% over 30  54.8% black, 42.8% white, 15% Latino  87.8% reported ever testing for HIV with 2.8% reporting being HIV+  38.6% reported having an HIV test within the last year  16.0% reported having an HIV test within the last 6 months  57.7% ever tested for Hepatitis C  52.1% told they had Hepatitis (95.0% Hep C)
  • IDU2 Testing DataDemographic IDU2 IDU2Group % HIV Positive % New (Tested = 536) PositivesTotal 8.9% 68.1%GenderMale 7.7% 70.0%Female 12.9% 64.7%RaceBlack 14.3% 65.7%White 2.6% 80.0%Latino 8.6% 71.4%
  • IDU2 Testing DataDemographic IDU2 IDU2Group % HIV Positive % New (Tested = 536) PositivesAge Group 18-24 0.0% 0.0% 25-44 3.8% 66.7% 45+ 13.5% 60.5%Geographic Area Kensington 4.2% 66.6% NW 12.5% 100.0% North 8.6% 76.9% West 23.4% 55.5%
  • What is a High-Risk Heterosexual? Past definitions  Multiple sexual partners  Sexual partners’ risks New definitions evaluated in NHBS-HET1  Geography (HIV is clustered in high-poverty neighborhoods)  Social networks (Some social and sexual networks have high HIV despite equal individual risks, greater inter- network mixing)
  • HIV Prevalence NHBS-HET1 2006-2007 HIV Test Result N (%) Negative 14,543 (98) Positive 294 (2) Total 14,837 (100)2% HIV prevalence is 10 to 20 times greaterthan that among all heterosexuals in the U.S.
  • HIV Prevalence, by Census Tract Poverty NHBS-HET1 2006-2007 Percent HIV-positive Chi-Square Trend, p< 0.0001 0 − 9% 10 − 19% 20 − 29% 30 − 39% ≥ 40% Proportion of Census Tract Residents Living Below the Poverty Level
  • HIV Prevalence, by Income NHBS-HET1 2006-2007Percent HIV-positive Chi-Square Trend, p< 0.0001 0 − 9,999 10 − 19,999 20 − 49,999 ≥ 50,000 Annual Household Income (in Dollars)
  • HIV Prevalence, by Income NHBS-HET1 2006-2007Percent HIV-positive 0 − 9,999 10 − 19,999 20 − 49,999 ≥ 50,000 Annual Household Income (in Dollars)
  • HIV Prevalence, by Income NHBS-HET1 2006-2007Percent HIV-positive 6X Greater 0 − 9,999 10 − 19,999 20 − 49,999 ≥ 50,000 Annual Household Income (in Dollars)
  • HIV Prevalence, Multivariable Model* NHBS-HET1 2006-2007Low socioeconomic status wasassociated with higher HIV prevalence: • Low income • Limited education • Unemployment • Resident of city • Sex with an opposite-gender partner in the past year • English- or Spanish-speaking*Controlling forcity, sex, race/ethnicity, age, education, employment, income, homelessstatus, crack use, exchange sex, and STD diagnosis.
  • HIV Surveillance & Census Data 37 States with HIV Reporting 2007Heterosexuals Living with HIVPersons (in thousands) African- Latino White American
  • HIV Surveillance & Census Data 37 States with HIV Reporting 2007Heterosexuals Living with HIV Adult & Adolescent PopulationPersons (in thousands) Persons (in millions) African- Latino White African- Latino White American American
  • Ratio of Heterosexuals Livingwith HIV to the Population–African-Americans: > 20 times greaterLatinos: 6 times greater
  • HIV Prevalence, by Race/Ethnicity NHBS-HET1 2006-2007Percent HIV-positive p= 0.14 African- Latino White American
  • HIV Prevalence, by Race/Ethnicity NHBS-HET1 2006-2007 All Census Tracts High Poverty Census TractsPercent HIV-positive Percent HIV-positive p= 0.73 p= 0.14 African- Latino White African- Latino White American American
  • HIV Prevalence, by Race/Ethnicity NHBS-HET1 2006-2007 All Census Tracts High Poverty Census TractsPercent HIV-positive Percent HIV-positive p= 0.73 p= 0.14 African- Latino White African- Latino White American American
  • HIV Prevalence, by Race/Ethnicity NHBS-HET1 2006-2007 All Census Tracts High Poverty Census TractsPercent HIV-positive Percent HIV-positive p= 0.73 p= 0.14 African- Latino White African- Latino White American American
  • HIV Prevalence, by Risk Behavior NHBS-HET1 2006-2007 Yes NoPercent HIV-positive p< 0.0001 p< 0.0001 p< 0.0001 Crack Exchange STD Use Sex Diagnosis
  • Summary● HIV prevalence was very high● Low socioeconomic status was associated with higher HIV prevalence● Racial and ethnic disparities in HIV prevalence were substantially less than those in the general population● Crack use and exchange sex were not associated with higher HIV prevalence
  • NHBS-HET2 Methods RDS method chosen for NHBS-HET2 Eligibility Criteria  Between the ages of 18-60  Male or female  Had vaginal or anal sex with a person of the opposite-sex in the past 12 months  Lives in the EMA  Able to complete the interview in English or Spanish
  • NHBS-HET2 Data 617 HET screened in Philadelphia 552 HET interviewed 510 met the HET definition  42.5% male, 57.5% female  25.3% 18-24  84.3% black, 2.2% white, 12.4% Latino, 1.2% other  94.9% had never injected drugs, 5.1% past IDU  15.9% currently or previously homeless
  • NHBS-HET2 data Education  34.5% less than high school education  54.5% high school education  10.0% with vocational/tech or some college  1.0% college graduate Poverty  10.6% above poverty guideline  87.6% at or below poverty
  • HET2 Demographics HIV Testing  76.3% reported ever testing for HIV with 2.8% reporting being HIV+  20.3% reported having an HIV test within the last 6 months  28.4% reported having an HIV test within the last year
  • HET2 Testing DataTested # HIV Positive % New PositiveAll Participants 4.4% (N=24) 79.2%Low SES 4.5% (N=23)Not Low SES 2.8% (N=1)Male 5.9% (N=13)Female 3.4% (N=10)Black 5.1% (N=22)Latino 1.6% (N=1)White 0.0% (N=0)
  • HET2 Testing DataDemographic HET2 HET2Group % HIV Positive % New (Tested = 552) PositivesAll Participants 4.3% 79.2%Gender Male 5.4% 84.6% Female 3.6% 72.7%Race/Ethnicity Black 5.0% 78.3% Latino 1.4% 100.0% White 0.0% 0.0%
  • HET2 Testing DataDemographic HET2 HET2Group % HIV Positive % New (Tested = 552) PositivesAge 18-24 1.5% 50.0% 25-44 3.5% 75.0% 45+ 7.4% 85.7%Low SES 3.4% 84.2%Not Low SES 0.9% 60.0%
  • Linkage to care
  • Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • 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
  • 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
  • Retention in care
  • Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • 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
  • 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
  • Population Sizes Population Sizes Value Data Source(s)Row A. Number of persons living 11,569 Local HARS data with AIDS (PLWA), for the period of 12/31/2011Row B. Number of persons living 7,523 Local HARS data with HIV (PLWH)/non- AIDS/aware, for the period of 12/31/2011Row C. Total number of 19,092 Local HARS data HIV+/aware for the period of 12/31/2011
  • Care Patterns Value Data Source(s)Row D. Number of PLWA 9,948 Surveillance Data who received the (Lab Data) specified HIV CAREWare primary medical care during the 12- month period of 2011Row E. Number of 5,132 Surveillance Data PLWH/non-AIDS (Lab Data) who received the CAREWare specified HIV primary medical care during the 12- month period of 2011
  • Row F. Total number of 15,080 HIV+/aware who received the specified HIV primary medical care during the 12-month period of 2011
  • Calculated Results Value CalculationRow G. Number of PLWA who 1,621 =A–D did not receive primary (14.0%) medical services during the 12-month period of 2011Row H. Number of PLWH/non- 2,391 =B–E AIDS who did not receive (31.8%) primary medical services during the 12-month period of 2011Row I. Total of HIV+/aware not 4,012 =G+H receiving specified (21.0%) primary medical care services (quantified estimate of unmet need
  • 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
  • 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
  • Disparities
  • Philadelphia Engagement in Care, 200925000 1918820000 100% 15753 82% 1189415000 62% 9944 8751 52% 46%10000 5775 30% 5000 0
  • Engagement in Care by Sex, 2009 Male Female12000 600010000 50008000 40006000 30004000 20002000 1000 0 0
  • Engagement in Care by Race/Ethnicity, 200912000100008000600040002000 0 Diagnosed In Care On ART Suppressed Black White Hispanic
  • Engagement in Care by Mode of Transmission, 2009600050004000300020001000 0 Diagnosed In Care On ART Suppressed MSM HET male HET female
  • Engagement in Care by Age Group, 2009600050004000300020001000 0 Diagnosed In Care On ART Suppressed 18-24 25-34 35-44 45-54 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
  • 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.
  • The EndQUESTIONS?