The document summarizes HIV engagement in care data for Philadelphia and nationally. It finds that in Philadelphia in 2009, 82% of people living with HIV were aware of their infection, 62% were linked to care, 52% were retained in care, 46% were prescribed antiretroviral therapy (ART), and 30% had viral suppression. Nationally, the rates were slightly higher. The epidemic in Philadelphia primarily affects minorities and transmission is mostly through men who have sex with men and heterosexual contact. While new AIDS cases have declined 25%, growing numbers are living with HIV. Around 20-30% have unmet needs and are not engaged in regular HIV care.

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
M A R C H 2 7 , 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
 4,205 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. HIV Prevalence in Philadelphia EMA
(reported thru 6/30/2012)
 25,968 PLWHA (aware)
 15,178 AIDS cases
 10,790 HIV cases
 5,700 estimated to be
living with HIV and
unaware
 0.5% Philadelphia EMA
residents estimated to be
HIV+
 Rates (known) vary by
race
 1.4% of blacks
 0.9% of Latinos
 0.2% of whites
 Rates vary by sex
 0.7% of males
 0.3% of females

20. 20
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

21. 21
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

22. 22
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

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

24. 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+

25. 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

28. 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

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

31. 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

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

36. Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMA
EMA
Total
N=2,221
EMA
%
Philadelphia
N=1,606
%
PA
N=378
%
NJ
N=237
%
Race/Ethnicity
White, non-Hispanic 481 21.7 16.1 38.9 32.1
Black, non-Hispanic 1,313 59.1 64.1 46.8 45.1
Hispanic 372 16.7 17.8 10.0 20.3
Asian/PI 3 0.2 1.2 2.4 2.1
American Indian/Alaskan
Native
4
1.5
0.2
0.0
0.0
Multi-Race 18 0.8 0.6 1.9 0.4
Unknown 0 0.0 0.0 0.0 0.0
Gender
Male 1,634 73.6 73.6 74.6 71.7
Female 587 26.4 26.4 25.4 28.3

37. Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMA
EMA
Total
N=2,221
EMA
%
Philadelphia
N=1,606
%
PA
N=378
%
NJ
N=237
%
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 25.7
Mode of Transmission
Men who have sex with men 840 37.8 39.5 29.9 38.8
Injection drug users 222 10.0 9.5 14.6 6.3
Men who have sex with men
and inject drugs
50 2.3 2.2 2.9 1.3
Heterosexuals 813 36.6 35.4 36.0 46.0
Other/Hemophilia/blood
transfusion
0 0.0 0.0 0.0 0.0
Perinatal Exposure 18 0.8 0.6 1.9 0.8
Risk not reported or identified 192 8.6 9.5 10.1 0.8

38. Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMA
EMA
Total
N=2,221
EMA
%
Philadelphia
N=1,606
%
PA
N=378
%
NJ
N=237
%
Insurance
Medicaid 411 18.5 23.1 0.0 16.9
Private 414 18.6 21.9 0.0 26.6
No Coverage 167 7.5 7.7 0.0 18.1
Other Public Funding 305 13.7 18.4 0.0 3.8
Unknown 924 41.6 28.9 100.0 34.6

39. 39
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

40. Who is unaware?

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

42. Concurrent HIV/AIDS, 2010

43. Concurrent HIV/AIDS, 2010

44. Linkage to care

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

46. 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

47. 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

48. Retention in care

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

50. 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

51. 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

52. Population Sizes Value Data Source(s)
Row A. Number of persons living
with AIDS (PLWA), for
the period of
12/31/2011
11,569
(15,178)
Local eHARS data
(EMA data)
Row B. Number of persons living
with HIV (PLWH)/non-
AIDS/aware, for the
period of 12/31/2011
7,523
(10,090)
Local eHARS data
(EMA data)
Row C. Total number of
HIV+/aware for the
period of 12/31/2011
19,092
(25,968)
Local eHARS data
(EMA data)
Population Sizes

53. 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
(13,053)
Surveillance Data
(Lab Data),
CAREWare
(EMA data)
Row E. Number of
PLWH/non-AIDS
who received the
specified HIV
primary medical
care during the
12-month period
of 2011
5,132
(7,370)
Surveillance Data
(Lab Data)
CAREWare
(EMA data)

54. Row F. Total number of
HIV+/aware who
received the
specified HIV
primary medical
care during the 12-
month period of
2011
15,080
(20,423)

55. 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
(2,125)
(14.0%)
= A – D
(EMA data)
Row H. Number of PLWH/non-
AIDS who did not receive
primary medical services
during the 12-month
period of 2011
2,391
(3,420)
(31.8%)
= B – E
(EMA data)
Row I. Total of HIV+/aware not
receiving specified
primary medical care
services (quantified
estimate of unmet need
4,012
(5,545)
(21.0%)
= G + H
(EMA data)

56. 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

57. 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

58. Disparities

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

61. Engagement in Care by Sex, 2009
82%
47%
43%
35%
0
2000
4000
6000
8000
10000
12000
Male
82%
67%
54%
35%
0
1000
2000
3000
4000
5000
6000
Female

63. Engagement in Care by Race/Ethnicity, 2009
82%
82%
82%
49%
54% 68%
42%
50% 60%
31%
45%
39%
0
2000
4000
6000
8000
10000
12000
Black White Hispanic
Diagnosed In Care On ART Suppressed

65. Engagement in Care by Mode of Transmission,
2009
82%
82%
4668
49%
48%
64%
46%
43%
51%
39%
32% 33%
0
1000
2000
3000
4000
5000
6000
MSM HET male HET female
Diagnosed In Care On ART Suppressed

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

68. 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

69. 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

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