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

1. K A T H L E E N A . B R A D Y , M D
M E D I C A L D I R E C T O R / M E D I C A L
E P I D E M I O L O G I S T
A I D S A C T I V I T I E S C O O R D I N A T I N G O F F I C E
J A N U A R Y 9 , 2 0 1 3
The HIV Engagement in Care
Cascade

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

12. Philadelphia Engagement in Care, 2009
19188
100% 15753
82% 11894
62% 9944
52%
8751
46% 5775
30%
0
5000
10000
15000
20000
25000

13. For every 100 people living with HIV:
US
Number
82
Are aware of their
infection
66 Are linked to HIV care
37 Stay in HIV care
33
Get antiretroviral
therapy
25
Have a very low amount
of virus in their body
Philadelphia
Number
82
Are aware of their
infection
62 Are linked to HIV care
52 Stay in HIV care
46
Get antiretroviral
therapy
30
Have a very low amount
of virus in their body
2009 Data

14. Who is Aware?

15. Philadelphia Engagement in Care, 2009
19188
100% 15753
82% 11894
62% 9944
52%
8751
46% 5775
30%
0
5000
10000
15000
20000
25000

18. HIV Prevalence in Philadelphia
(reported thru 6/30/2012)
 19,157 PLWHA (aware)
 11,583 AIDS cases
 7,574 HIV cases
 5,092 estimated to be
living with HIV and
unaware
 1.59% Philadelphia
residents estimated to be
HIV+
 Rates (known) vary by
race
 2.1% of blacks
 1.5% of Latinos
 0.7% of whites
 Rates vary by sex
 1.9% of males
 0.7% of females

19. 19
HIV/AIDS Cases by Date of Diagnosis
1178
1302
1177
1001
898
1200
894 895 907
861 821
712 756
652
452
221 239
176
940 918 921 893
729 712
1308
0
200
400
600
800
1000
1200
1400
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Year
NumberofCases
AIDS HIV

20. 20
HIV/AIDS Cases by Sex and Date of
Diagnosis
0
200
400
600
800
1000
1200
1400
1600
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
Year
NumberofCases
AIDS Female AIDS Male HIV Female HIV Male

21. 21
HIV Cases by Race/Ethnicity and Date of
Diagnosis
171
142 127
106 110
575 594
534
479 498
133 146
210
127
95
0
100
200
300
400
500
600
700
2006 2007 2008 2009 2010 2011
Year
NumberofCases
White AfrAm Hispanic

22. HIV diagnoses by risk group, 2007-2011
0
100
200
300
400
500
600
2007 2008 2009 2010 2011
MSM IDU HET

23. Demographics of new positives, MSM
New HIV diagnoses among
MSM by race, 2007-2011
0%
10%
20%
30%
40%
50%
60%
70%
Black Latino White
New HIV diagnoses among
MSM by age, 2007-2011
0%
10%
20%
30%
40%
50%
60%
13 - 24 25 - 44 45+

24. New HIV diagnoses among
MSM youth, 2007-2011
New HIV diagnoses among
MSM youth, 2007-2011
75.4%
9.3%
12.6%
Race
Black White Latino
7.6%
92.0%
Age
13-17 18-24
Demographics of new positives, MSM youth

27. New HIV diagnoses among
IDU, 2007-2011
New HIV diagnoses among
IDU, 2007-2011
44.1%
38.0%
16.0%
Race
Black White Latino
10.2%
53.1%
36.2%
Age
13-24 25-44 45+
Demographics of new positives, IDU

28. Demographics of new positives, IDU
2007 - 2011
70.1%
29.8%
Sex
Male
Female

30. New HIV diagnoses among
HET, 2007-2011
New HIV diagnoses among
HET, 2007-2011
72.7%
15.0%
8.8%
Race
Black White Latino
3.8%
50.6%
34.6%
Age
13-24 25-44 45+
Demographics of new positives, Heterosexuals

31. Demographics of new positives, HET
2007 - 2011
50.7%
49.2%
Sex
Male
Female

35. 35
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

36. Who is getting infected?

37. Philadelphia Engagement in Care, 2009
19188
100% 15753
82% 11894
62% 9944
52%
8751
46% 5775
30%
0
5000
10000
15000
20000
25000

38. 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.

39. Incidence vs. Prevalence
HIV Prevalence = the total number of HIV cases that exist at a
specific time within a specific population.
HIV Incidence = the number of individuals newly infected
with HIV within a given period of time (6 - 12
months).
20061981 2007
20061981 2007

40. Serologic
Testing
Algorithm for
Recent
HIV
Seroconversion
What is STARHS?

41. Remnant HIV+
Serum
Supplemental Data
STARHS
Testing
using BED
Assay
Includes:
•Race, sex, mode of
transmission
•Testing history &
reasons for testing
(Calculating weights)
•Any exclusionary
info (AIDS diagnosis,
prior recent ART)
•Adjust for LFU, QNS
HIV Incidence Estimation
Requirements for HIV Incidence
Surveillance

42. CDC STARHS Test Results
 (+) standard test and (+) STARHS test
= long-standing HIV infection
 (+) standard test and (-) STARHS test =
recent HIV infection

43. 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

44. 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

45. HIV Incidence Trends by Demographic Groups
0
200
400
600
800
1000
2006 2007 2008 2009 2010
Total
Age 13-24
Male
Black
MSM

46. HIV Incidence Trends by Demographic Groups
0
200
400
600
800
1000
2006 2010
Total
Age 13-24
Male
Black
MSM

47. Estimated Incidence Rates - 2010
Population Population in
2010 (13 +)
ESTIMATED
Incidence
Estimate,
20010
Estimated
Case Rate
per
100,000
95% CI
lower
bound
95% CI
upper
bound
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 poverty
Data Source: PDPH/AACO HIV Incidence Surveillance Program

48. 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

49. Who is unaware?

50. Philadelphia Engagement in Care, 2009
19188
100% 15753
82% 11894
62% 9944
52%
8751
46% 5775
30%
0
5000
10000
15000
20000
25000

51. Concurrent HIV/AIDS, 2010

52. Concurrent HIV/AIDS, 2010

53. 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)

54. 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

55. 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

56. 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

57. Philadelphia NHBS-MSM3, 2011
76.4% 76.2% 76.1%
78.5%
NHBS-MSM3
% of MSM who had an
HIV test in the last 12
months
ALL MSM Black MSM
LatinoMSM White MSM
Demograp
hic Group
MSM3
% HIV
Positive
Tested =
519
MSM3
% New
Positiv
es
Total 11.9% 29.0%
Race
Black 14.9% 31.8%
White 8.5% 16.7%
Latino 6.8% 50.0%
Age
18-24 8.2% 50.0%
25-44 10.6% 35.1%
45+ 19.8% 21.1%

58. 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)

59. IDU2 Testing Data
Demographic
Group
IDU2
% HIV Positive
(Tested = 536)
IDU2
% New
Positives
Total 8.9% 68.1%
Gender
Male 7.7% 70.0%
Female 12.9% 64.7%
Race
Black 14.3% 65.7%
White 2.6% 80.0%
Latino 8.6% 71.4%

60. IDU2 Testing Data
Demographic
Group
IDU2
% HIV Positive
(Tested = 536)
IDU2
% New
Positives
Age 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%

61. 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)

62. HIV Prevalence
NHBS-HET1 2006-2007
HIV Test Result
Negative
Positive
Total
14,543
294
14,837
N
(98)
(2)
(100)
(%)
2% HIV prevalence is 10 to 20 times greater
than that among all heterosexuals in the U.S.

63. 10−19% 20−29% ≥ 40%
Proportion of Census Tract Residents Living Below the Poverty Level
0−9%
PercentHIV-positive
30−39%
HIV Prevalence, by Census Tract Poverty
NHBS-HET1 2006-2007
Chi-Square Trend, p< 0.0001

64. 10−19,999 20−49,999 ≥ 50,000
Annual Household Income (in Dollars)
0−9,999
PercentHIV-positive HIV Prevalence, by Income
NHBS-HET1 2006-2007
Chi-Square Trend, p< 0.0001

65. 10−19,999 20−49,999 ≥ 50,000
Annual Household Income (in Dollars)
0−9,999
PercentHIV-positive HIV Prevalence, by Income
NHBS-HET1 2006-2007

66. 10−19,999 20−49,999 ≥ 50,000
Annual Household Income (in Dollars)
0−9,999
PercentHIV-positive HIV Prevalence, by Income
NHBS-HET1 2006-2007
6X Greater

67. *Controlling for city, sex, race/ethnicity, age, education, employment,
income, homeless status, crack use, exchange sex, and STD diagnosis.
HIV Prevalence, Multivariable Model*
NHBS-HET1 2006-2007
Low socioeconomic status was
associated 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

68. HIV Surveillance & Census Data
37 States with HIV Reporting 2007
Persons(inthousands)
Heterosexuals Living with HIV
African-
American
Latino White

69. HIV Surveillance & Census Data
37 States with HIV Reporting 2007
Persons(inthousands)
Heterosexuals Living with HIV
African-
American
Latino White
Persons(inmillions)
Adult & Adolescent Population
African-
American
Latino White

70. Ratio of Heterosexuals Living
with HIV to the Population–
African-Americans:
> 20 times greater
Latinos:
6 times greater

71. HIV Prevalence, by Race/Ethnicity
NHBS-HET1 2006-2007
African-
American
Latino White
PercentHIV-positive
p= 0.14

72. HIV Prevalence, by Race/Ethnicity
NHBS-HET1 2006-2007
All Census Tracts
African-
American
Latino White
PercentHIV-positive
African-
American
Latino White
High Poverty Census Tracts
PercentHIV-positive
p= 0.14
p= 0.73

73. HIV Prevalence, by Race/Ethnicity
NHBS-HET1 2006-2007
All Census Tracts
African-
American
Latino White
PercentHIV-positive
African-
American
Latino White
High Poverty Census Tracts
PercentHIV-positive
p= 0.14
p= 0.73

74. HIV Prevalence, by Race/Ethnicity
NHBS-HET1 2006-2007
All Census Tracts
African-
American
Latino White
PercentHIV-positive
African-
American
Latino White
High Poverty Census Tracts
PercentHIV-positive
p= 0.14
p= 0.73

75. Exchange
Sex
STD
Diagnosis
Crack
Use
PercentHIV-positive
Yes No
HIV Prevalence, by Risk Behavior
NHBS-HET1 2006-2007
p< 0.0001 p< 0.0001p< 0.0001

76. ● 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
Summary

77. 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

78. 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

79. 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

80. 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

81. HET2 Testing Data
Tested # HIV Positive % New Positive
All 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)

82. HET2 Testing Data
Demographic
Group
HET2
% HIV Positive
(Tested = 552)
HET2
% New
Positives
All 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%

83. HET2 Testing Data
Demographic
Group
HET2
% HIV Positive
(Tested = 552)
HET2
% New
Positives
Age
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%

84. Linkage to care

85. Philadelphia Engagement in Care, 2009
19188
100% 15753
82% 11894
62% 9944
52%
8751
46% 5775
30%
0
5000
10000
15000
20000
25000

86. Linkage to Care 2009-2010
by Age, Race
74%
68%
73%
79%
75%
76%
72%
76%
81%
60%
65%
70%
75%
80%
85%
Total 13-24 25-34 35-44 45-54 55+ Black Hispanic White

87. Linkage to Care 2009-2010
by Sex, Mode
74%
68%
73% 72%
74% 75%
43%
69%
81%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Total Male Female MSM Male IDU Male HET Male
MSM/IDU
Female IDU Female HET

88. Retention in care

89. Philadelphia Engagement in Care, 2009
19188
100% 15753
82% 11894
62% 9944
52%
8751
46% 5775
30%
0
5000
10000
15000
20000
25000

90. 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

91. 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

92. Population Sizes Value Data Source(s)
Row A. Number of persons living
with AIDS (PLWA), for
the period of
12/31/2011
11,569 Local HARS data
Row B. Number of persons living
with HIV (PLWH)/non-
AIDS/aware, for the
period of 12/31/2011
7,523 Local HARS data
Row C. Total number of
HIV+/aware for the
period of 12/31/2011
19,092 Local HARS data
Population Sizes

93. Care Patterns Value Data Source(s)
Row D. Number of PLWA
who received the
specified HIV
primary medical
care during the 12-
month period of
2011
9,948 Surveillance Data
(Lab Data)
CAREWare
Row E. Number of
PLWH/non-AIDS
who received the
specified HIV
primary medical
care during the 12-
month period of
2011
5,132 Surveillance Data
(Lab Data)
CAREWare

94. Row F. Total number of
HIV+/aware who
received the
specified HIV primary
medical care during
the 12-month period
of 2011
15,080

95. Calculated Results Value Calculation
Row G. Number of PLWA who
did not receive primary
medical services during
the 12-month period of
2011
1,621
(14.0%)
= A – D
Row H. Number of PLWH/non-
AIDS who did not receive
primary medical services
during the 12-month
period of 2011
2,391
(31.8%)
= B – E
Row I. Total of HIV+/aware not
receiving specified
primary medical care
services (quantified
estimate of unmet need
4,012
(21.0%)
= G + H

96. Unmet need by demographic groups, 2011
33.6%
13.4%
27.4%
15.5%
31.8%
15.2%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
HIV AIDS
Black White Hispanic
33.4%
15.2%
28.1%
10.6%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
HIV AIDS
Male Female

97. Unmet need by insurance status, 2011
28.3%
13.5%
22.4%
12.6%
33.7%
7.5%
46.4%
29.6%
43.1%
26.6%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
HIV AIDS
Medicaid Private Other public Unknown None

98. Disparities

99. Philadelphia Engagement in Care, 2009
19188
100% 15753
82% 11894
62% 9944
52%
8751
46% 5775
30%
0
5000
10000
15000
20000
25000

101. Engagement in Care by Sex, 2009
0
2000
4000
6000
8000
10000
12000
Male
0
1000
2000
3000
4000
5000
6000
Female

103. Engagement in Care by Race/Ethnicity, 2009
0
2000
4000
6000
8000
10000
12000
Diagnosed In Care On ART Suppressed
Black White Hispanic

105. Engagement in Care by Mode of Transmission,
2009
0
1000
2000
3000
4000
5000
6000
Diagnosed In Care On ART Suppressed
MSM HET male HET female

107. Engagement in Care by Age Group, 2009
0
1000
2000
3000
4000
5000
6000
Diagnosed In Care On ART Suppressed
18-24 25-34 35-44 45-54 55+

108. 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

109. clinicaloptions.com/hiv
Starting Antiretroviral Therapy in 2012: A Compendium of Interactive Cases
What Will It Take to Substantially Reduce
HIV Transmission in an Entire Population?
•Answer: Treatment AND Prevention
•Gardner EM, et al. Clin Infect Dis. 2011;52:793-800.
•200,000
•600,000
•0
•800,000
•1,000,000
•1,200,000
•400,000
•19% •22%
•34% •28% •21%
•66%
•NumberofIndividuals
•Current •DX
90%
•Engage
90%
•Treat
90%
•VL < 50
in 90%
•Dx,
Engage, Tx,
and VL < 50
in 90%
Undiagnosed HIV
Not linked to care
Not retained in care
ART not required
ART not utilized
Viremic on ART
Undetectable
HIV-1 RNA

110. Q U E S T I O N S ?
The End