This document summarizes disparities in Philadelphia's HIV continuum of care. It identifies several priority populations that experience lower rates of HIV status awareness, retention in medical care, and viral load suppression. These include racial/ethnic minority youth, transgender persons who have sex with men, heterosexual men of color, and persons who inject drugs. The document also finds geographic disparities, with lower continuum measures in collar counties surrounding Philadelphia. It concludes by recommending several areas for action to decrease disparities, such as increasing PrEP access, HIV testing, and linkage to and retention in medical care.

1. Epidemiology Update
Disparities in the HIV Continuum of Care
Kathleen A. Brady, MD
Philadelphia Department of Public Health
AIDS Activities Coordinating Office
February 9, 2018

2. Overview
1 HIV Continuum of Care
2 Priority Populations
3 Trends in Disparities
4 Geographic Disparities
5 Conclusions

3. HIV Continuum of Care

4. Why a Continuum?
• For individuals living with HIV to fully benefit from antiretroviral
therapy, they need to:
• Know that they are HIV positive
• Be engaged in regular HIV care
• Receive and adhere to effective ART
• Various obstacles, or barriers, contribute to gaps in testing and
care
• An individual’s care status can fluctuate, moving forwards or
backwards

5. Parts of the HIV Continuum
• HIV-Diagnosed/ Unaware estimates
• Linkage to HIV medical care (within
90 days of HIV diagnosis)
• Retention in HIV medical care (≥2
labs at least 90 days apart in a year)
• Viral load suppression (<200
copies/mL)

6. Newly Diagnosed HIV, Philadelphia 2016
Populations Most Affected
Rates of Newly Diagnosed HIV/AIDS per 100,000
Population by Year of Diagnosis and Risk Group

7. Priority Populations

8. Priority = HIV Continuum Disparities
• Higher rates of new HIV diagnoses/transmissions
• Lower rates of HIV status awareness
• Lower rates of retention in medical care
• Lower rates of viral load suppression
8

9. Priority Populations, Philadelphia EMA 2018
• Racial/Ethnic minority youth (ages 13-24)
• Transgender persons who have sex with men (TSM)
• MSM of color ≥25 years of age
• Heterosexual men of color
• Women of color
• Persons who inject drugs (PWID)

10. Racial/Ethnic Minority Youth (ages 13-24), 2016
91.6
87.3
50.1
54.9
48.6
83.7
59
53.1
0
20
40
60
80
100
Percent
Diagnosed
Linked to
Care
Retained in
Care
Virally
Suppressed
EMA
Minority Youth
Note:
• High rates of
new infections
• Very low rates of
awareness
• Higher rate of
retention in care
• Lower rate of
viral suppression

11. Transgender persons who have sex with men (TSM), 2016
91.6
87.3
50.1
54.9
82.9
70 69.5 65.2
0
20
40
60
80
100
Percent
Diagnosed
Linked to
Care
Retained in
Care
Virally
Suppressed
EMA TSM
Note:
• High rates of
new infections
• Lower rate of
awareness
• Lower rate of
linkage to care
• Higher rates of
retention in care
and viral
suppression
• *limited data*

12. MSM of color ≥25 years of age, 2016
91.6
87.3
50.1
54.9
88.1
92
48.6
54
0
20
40
60
80
100
Percent
Diagnosed
Linked to Care Retained in
Care
Virally
Suppressed
EMA MSM ≥25 Note:
• High rates of
new infections
• Low rates of
awareness
• No disparities in
care

13. Heterosexual men of color, 2016
91.6
87.3
50.1
54.9
90.7
82.4
43.6
51.2
0
20
40
60
80
100
Percent
Diagnosed
Linked to
Care
Retained in
Care
Virally
Suppressed
EMA
HET Men of Color
Note:
• Disparity in rate
of new HIV
diagnoses
• Lower rate of
retention in care
• Lower rate of
viral suppression

14. Women of color, 2016
91.6
87.3
50.1
54.9
94.2
75.4
50.7
53.2
0
20
40
60
80
100
Percent
Diagnosed
Linked to
Care
Retained in
Care
Virally
Suppressed
EMA
Women of Color
Note:
• Higher
awareness
• Disparity in rate
of new HIV
diagnoses (not
shown)

15. Persons who inject drugs, 2016
91.6 87.3
50.1
54.9
99.8
58.6
49.7 47.6
0
20
40
60
80
100
Percent
Diagnosed
Linked to
Care
Retained in
Care
Virally
Suppressed
EMA
PWID
Note:
• Lower rate of
new diagnoses
• Lower rate of
linkage to care
• Lower rate of
viral suppression

16. Trends in Disparities
Philadelphia

17. Racial/Ethnic Minority Youth (ages 13-24)
17
0
10
20
30
40
50
60
70
80
90
100
2012 2013 2014 2015 2016
Linkage Overall
Linkage Youth
Retention Overall
Retention Youth
Suppression Overall
Suppression Youth

18. Transgender Persons who have sex with men (TSM)
0
10
20
30
40
50
60
70
80
90
100
2012 2013 2014 2015 2016
Linkage Overall
Linkage TSM
Retention Overall
Retention TSM
Suppression Overall
Suppression TSM

19. MSM of color ≥25 years of age
0
10
20
30
40
50
60
70
80
90
100
2012 2013 2014 2015 2016
Linkage Overall
Linkage MSM of Color
Retention Overall
Retention MSM of Color
Suppression Overall
Suppression MSM of Color

20. Heterosexual men of color
0
10
20
30
40
50
60
70
80
90
100
2012 2013 2014 2015 2016
Linkage Overall
Linkage HET Men of Color
Retention Overall
Retention HET Men of Color
Suppression Overall
Suppression HET Men of Color

21. Women of color
0
10
20
30
40
50
60
70
80
90
100
2012 2013 2014 2015 2016
Linkage Overall
Linkage Women of Color
Retention Overall
Retention Women of Color
Suppression Overall
Suppression Women of Color

22. Persons who inject drugs
0
10
20
30
40
50
60
70
80
90
100
2012 2013 2014 2015 2016
Linkage Overall
Linkage PWID
Retention Overall
Retention PWID
Suppression Overall
Suppression PWID

23. Geographic Disparities

25. Differences by Geography
• Lower rates of awareness in collar counties
• Lower rates of retention in care in collar counties
• Lower rates of viral suppression in collar counties
25

26. HIV Continuum Measures by Region, 2016
92.7
84.3
46.4
50.8
89.1
81.3
36.2
32.6
89.1
69.1
23.1
30.7
0
10
20
30
40
50
60
70
80
90
100
Percent
Diagnosed
Linked to
Care
Retained in
Care
Virally
Suppressed
Philadelphia
PA counties
NJ counties

27. Conclusions

28. Areas of action for decreasing disparities
• PrEP access and adherence support
• HIV Navigation Services
• Targeted HIV Testing
• Opt-out routinized HIV Testing in Health Care Settings/STD clinic/Jails
• HIV screening in Emergency Departments
• Linkage to care activities
• Syringe service programs
• Access to condoms
• Ryan White MCM
• CoRECT
28

29. Additional Areas of action for decreasing disparities
• Stigma
• Adherence
• Culturally competent programs
• Language barriers
• Community mobilization
• Leveraging the Ryan White Care system to improve health
outcomes
• Average/poor quality data on transgender persons
• Changing opioid epidemic, and the need for rapid outbreak
response planning
29

30. Next steps
• Implementation of activities under CDC Prevention/Surveillance
grant (18-1802)
• Expand CoRECT (Data to care activities)
• Restructuring of MCM in EMA
• Further research on interventions to improve viral suppression
once patients engaged in HIV care

31. Thank You!
Kathleen A. Brady, MD
Medical Director/Medical Epidemiologist
AIDS Activities Coordinating Office
Philadelphia Department of Public Health
E-Mail: kathleen.a.brady@phila.gov
Phone: (215)-685-4778