Kathleen Brady - HIV in Philadelphia (Annual Epidemiological Presentation)

HIV in Philadelphia
Kathleen A. Brady, MD
Medical Director/Medical Epidemiologist
AIDS Activities Coordinating Office
Philadelphia Department of Public Health
From Bench to Bus Stop
January 26, 2016

HIV Care Continuum
Adapted from
Eldred et al AIDS Patient Care STDs 2007;21(Suppl1):S1-S2
Cheever LW Clin Infect Dis 2007;44:1500-2
Not in HIV Care Engaged in HIV Care
Unaware of
HIV infection
Aware of
HIV infection
(not in care)
Receiving some
medical care but
not HIV care
Entered HIV
care but lost to
follow-up
Cyclical or
intermittent user
of HIV care
Fully engaged
in HIV care

Prevalence-Based Continuum
 Denominator:
 National HIV Surveillance System
 Persons aged ≥13 years with diagnosed or undiagnosed HIV infection
in the United States
 Estimates derived using back-calculation
 Persons with HIV infection at the end of the specified year
(2009, 2010, 2011, 2012)
 Numerators:
 Persons with diagnosed HIV infection in the United States; calculated
as a part of overall prevalence estimate for specified year
 Medical Monitoring Project
 Persons aged ≥18 years with diagnosed HIV infection in the United
States and Puerto Rico
 Received HIV medical care - Care visit during January to April
of data collection year (2009, 2010, 2011, 2012)
 Prescribed antiretroviral therapy - Documentation of
antiretroviral prescription in the medical record
 Viral Suppression – Most recent viral load test result in the
preceding year was undetectable or <200 copies/mL

Persons Living with Diagnosed or Undiagnosed HIV Infection
HIV Care Continuum Outcomes, 2012 — United States and Puerto
Rico
National HIV Surveillance System,: Estimated number of persons aged ≥13 years living with diagnosed or undiagnosed HIV infection (prevalence)
in the United States at the end of 2012. The estimated number of persons with diagnosed HIV infection was calculated as part of the overall
prevalence estimate.
Medical Monitoring Project: Estimated number of persons aged ≥18 years who received HIV medical care during January to April of 2012, were
prescribed ART, or whose most recent VL in the previous year was undetectable or <200 copies/mL—United States and Puerto Rico.

Diagnosis-Based Continuum
 Denominator:
 Persons aged ≥18 years with diagnosed HIV infection in the
United States and Puerto Rico
 Persons with diagnosed HIV infection by the end of the year
preceding the specified year (2008, 2009, 2010, 2011) and
alive at the end of the specified year (2009, 2010, 2011, 2012)
 Numerators:
 Medical Monitoring Project
 Persons aged ≥18 years with diagnosed HIV infection in
the United States and Puerto Rico
 Received HIV medical care - Care visit during January to
April of data collection year
 Prescribed antiretroviral therapy - Documentation of
antiretroviral prescription in the medical record
 Viral Suppression – Most recent viral load test result in
preceding year was undetectable or <200 copies/mL

Persons Living with Diagnosed HIV Infection
HIV Care Continuum Outcomes, 2012
United States and Puerto Rico
National HIV Surveillance System: Estimated number of persons aged ≥18 years diagnosed with HIV infection by year-end 2011 and alive at year-
end 2012—United States and Puerto Rico.
Medical Monitoring Project: Estimated number of persons aged ≥18 years who received medical care January to April of 2012, were prescribed
antiretroviral therapy, or whose most recent VL was undetectable or <200 copies/mL—United States and Puerto Rico.

2010 2011 2012 2013 2014
Link 30 Days* 71 75 75 72 77
Link 90 Days 79 81 81 78 82
0
10
20
30
40
50
60
70
80
90
100
Percentage(%)
Philadelphia HIV Linkage by Year
*Significant increase in linkage within 30 days between 2010 and 2014 (p=0.02)
Source: PDPH, AIDS Activities Coordinating Office, 2015

2011 2012 2013 2014
HIV Diagnosed 100 100 100 100
Retention* 47 51 52 52
Suppression* 44 49 50 53
0
10
20
30
40
50
60
70
80
90
100
Percentage(%)
Philadelphia Care Continuum Measures
*Significant increase between 2011 and 2014 (p<0.0001)

US (2012 Data) Philadelphia (2014 Data
Number
100 Diagnosed
80 Are linked to HIV care
54 Stay in HIV care
50
Get antiretroviral
therapy
42
Have a very low
amount of virus in their
body
Number
100 Diagnosed
82 Are linked to HIV care
52 Stay in HIV care
N/A
Get antiretroviral
therapy
53
Have a very low
amount of virus in their
body
For every 100 people living with HIV:

Rates of Diagnoses of HIV Infection Among Adults and
Adolescents, by Area of Residence, 2013
United States and 6 Dependent Areas
N= 47,957 Total rate = 18.0

Newly Diagnosed HIV (Non-AIDS) for
2012-2014, Philadelphia EMA
EMA
Total
N=2,120
EMA
%
Phila
N=1,433
%
PA
N=391
%
NJ
N=224
%
Race/Ethnicity
White, non-Hispanic 409 19.3 13.0 38.9 23.6
Black, non-Hispanic 1,335 63.0 70.1 45.3 52.0
Hispanic 307 14.5 14.1 10.0 22.3
Asian/Pacific Islander 30 1.4 1.6 1.8 0.0
American
Indian/Alaskan Native
9 0.4 0.6 0.3 0.0
Multi-Race 24 1.1 0.6 3.8 0.0
Unknown 6 0.3 0.0 0.0 2.0
Gender
Male 1,641 76.2 78.3 79.0 70.9

EMA
Total
N=2,120
EMA
%
Phila
N=1,433
%
PA
N=391
%
NJ
N=224
%
Age
<13 years 12 0.6 0.1 1.3 1.7
13 - 19 years 126 5.9 6.8 4.9 3.4
20-24 years 442 20.8 22.7 17.9 15.5
25-29 years 365 17.2 18.1 15.6 15.2
30-39 years 435 20.5 19.7 20.5 24.7
40-49 years 370 17.5 16.7 17.9 20.6
50+ years 370 17.5 15.9 22.0 18.9

EMA
Total
N=2,120
EMA
%
Phila
N=1,433
%
PA
N=391
%
NJ
N=224
%
Mode of Transmission
Men who have sex with
men (MSM)
1048 49.4 52.1 49.9 35.8
Injection drug users
(IDU)
140 6.6 6.8 5.1 7.8
MSM/IDU 24 1.1 1.2 1.3 0.7
Heterosexuals 786 37.1 37.5 33.5 39.9
Other/hemophilia/blood
transfusion
0 0.0 0.0 0.0 0.0
Perinatal exposures 15 0.7 0.3 1.3 1.7
Risk not reported or
identified
107 5.0 2.1 9.0 14.2

Newly Diagnosed HIV Cases, Deaths, and Living HIV Cases by Year
Philadelphia, 2008-2014
928 897
739 680 729 679 624
524 511 546
473 432 393
165*
18640
19237
19525
19157
19832
19564 19494
15000
15500
16000
16500
17000
17500
18000
18500
19000
19500
20000
0
200
400
600
800
1000
1200
1400
1600
1800
2000
2008 2009 2010 2011 2012 2013 2014
Newly Diagnosed Deaths Living HIV Cases
*Data incomplete due to reporting delays

Newly Diagnosed HIV 2014
• 624 Newly Diagnosed
cases
• 78.8% male at birth
• 67.6% black, 14.5%
Hispanic, 14.4% white
• 23.2% among 13-24
year olds
51.1%
5.4%
40.7%
0.4%
0.3% 1.9%
MSM IDU HET
MSM/IDU Pediatric NIR

19
HIV/AIDS Cases by Date of
Diagnosis
1086
1020
939
862
763 779
672
745
800
744
694 695 659
521
424
333 297 257 257
186 159
530 546 565 578
442 423
472 493 465
1266
0
200
400
600
800
1000
1200
1400
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
2013
Year
NumberofCases
AIDS HIV

Newly Diagnosed HIV Disease by Sex at
Birth (regardless of AIDS status)
0
100
200
300
400
500
600
2010 2011 2012 2013 2014
Year
NumberofCases
HIV Female HIV Male

Newly Diagnosed HIV Disease by Race/Ethnicity
(regardless of HIV status)
105 97
73
90
479
501 503
422
87
110
80 91
0
100
200
300
400
500
600
2010 2011 2012 2013 2014
Year
NumberofCases
White AfrAm Hispanic

22
Newly Diagnosed HIV Disease by Mode of
Transmission (regardless of AIDS status)
281
297
51
69
35 34
274
11 12
319
352
254
324324
29
9
0
50
100
150
200
250
300
350
400
2010 2011 2012 2013 2014
Year
NumberofCases
MSM IDU HetSx NIR

Newly Diagnosed HIV Disease by Age at Diagnosis
(regardless of HIV status)
39 32
219
265
251
211
138
126
111
127 133
120
136
32
43
134146149
152
159
112
0
50
100
150
200
250
300
2010 2011 2012 2013 2014
Year
NumberofCases
13-19 20-29 30-39 40-49 50+

Rates of Adults and Adolescents Living with Diagnosed HIV
Infection, by Area of Residence, Year-end 2012
United States and 6 Dependent Areas
N= 931,449 Total rate = 352.3

Proportion of Philadelphia Residents Diagnosed and Living with HIV by
Race/Ethnicity and Sex, 2014
2.9%
2.2%
1.1% 1.1%
0.8%
0.2%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
Black Males Hispanic
Males
Black
Females
White Males Hispanic
Females
White
Females
Overall Prevalence 1.3%
Epidemic Level 1.0%

PLWHA 2014
• 27,121 PLWHA (current
EMA residents)
• 71.7% male at birth
• 57.9% black, 14.9%
Hispanic, 23.2% white
• 48.0% among 50+ year
olds
35.6%
20.9%
35.4%
3.0%
1.5% 3.6%
MSM IDU HET
MSM/IDU Pediatric NIR

2013 Local Estimate of
HIV Incidence
• Local estimate of 508 new HIV infections in
2013 in adults and adolescents (95% CI, 333-
683)

HIV Incidence Trends by Demographic
Groups
0
200
400
600
800
1000
1200
2006 2007 2008 2009 2011 2012 2013
Total
Age 13-24
Male
Black
MSM

Estimated Incidence Rates - 2013
Population Population in
2010 (13 +)
ESTIMATED
Incidence
Estimate,
2013
Estimated
Case Rate
per
100,000
95% CI
lower
bound
95% CI
upper
bound
MSM 29,737 324 1,089.6 632.2 1,550.3
IDU 37,378 18 48.2 0 136.4
HET 294,682* 166 56.3 25.5 86.9
*Includes persons >13 living in poverty
Data Source: PDPH/AACO HIV Incidence Surveillance Program, 2015

Unaware Estimates by Select Demographic
Groups, Philadelphia, 2013
Demographic Group % Unaware (95% CI)
Sex
Female 7.5% (0.9 %-14.1%)
Male 11.5% (6.7%-15.4%)
Race/Ethnicity
Black 12.5% (8.4%-17.0%)
Hispanic 9.6% (1.4%-17.5%)
White/Other 4.7% (0.1%-11.1%)
Heterosexual 13.5% (9.0%-19.1%)
IDU (including MSM/IDU) 5.1% (2.9%-7.3%)
MSM 13.2% (8.2%-19.2%)
Total 10.4% (13.7% – 7.5%)

Non-Concurrent and Concurrent HIV/AIDS
Among Incident HIV Diagnosis 2014 (EMA)
Non-Concurrent Concurrent
HIV/AIDS
Total
N Row % N Row % N Col %
Total 739 72.9% 227 24.8% 917 100%
Sex
Male 579 81.4% 169 23.8% 711 77.5%
Female 160 77.7% 58 28.2% 206 22.5%
Race/Ethnicity
Black 440 78.7% 140 25.0% 559 61.0%
Hispanic 159 85.5% 46 24.7% 186 20.3%
White 116 81.7% 33 23.2% 142 15.5%
Other 24 80.0% 8 26.7% 30 3.3%

HIV/AIDS
Total
Age Group at HIV Diagnosis
<13 0 0.0% 0 0.0% 0 0.0%
13-19 41 95.3% * 7.0% 43 4.7%
20-24 141 93.4% 11 7.3% 151 16.5%
25-29 130 90.3% 22 15.3% 144 15.7%
30-39 152 77.6% 54 27.6% 196 21.4%
40-49 127 73.0% 64 36.8% 174 19.0%
50+ 148 70.8% 73 34.9% 209 22.8%

HIV/AIDS
Total
Transmission Risk
MSM 386 86.4% 81 18.1% 447 48.7%
IDU 45 86.5% 10 19.2% 52 5.7%
MSM/IDU 9 100.0% * 22.2% 9 1.0%
Heterosexual 270 73.0% 119 32.2% 370 40.3%
No identified risk 24 61.5% 15 38.5% 39 4.3%
Pediatric 0 0.0% 0 0.0% 0 0.0%
Geographic Area
Philadelphia 480 76.9% 144 23.1% 624 68.1%
PA Counties 110 69.2% 49 30.8% 159 17.3%
NJ Counties 100 74.6% 34 25.4% 134 14.6%

HIV CARE CONTINUUM BY RESIDENCE IN GEOGRAPHIC HOTSPOTS
Kathleen A. Brady, MD
37
100.0%
64.6%
33.0%
26.3%
100.0%
54.3%
24.0%
9.1%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Diagnosed Linked to Care Retained in Care Virally
Suppressed
Not a Hotspot Hotspot
p < .05
p < .05
p < .05
N=1,704

Percent Retained, Using ART and
Virally Suppressed

Overall Transgender
Linkage 90 Days 82 83
Retention 52 62
Suppression 53 62
0
10
20
30
40
50
60
70
80
90
100
Percentage(%)
2014 Care Continuum Measures: Transgender

Philadelphia HIV Care Continuum 2014
90%
47%
68%
48%
87%
44%
63%
47%
87%
44%
66%
48%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Diagnosed Engaged in Care Prescribed ART Virally Suppressed
ALL PLWHA MSM of Color Black MSM
Hispanic MSM Other MSM of Color White MSM

National HIV Behavioral Surveillance
• Conducted 2004-Present
• Establish and maintain a
surveillance system among
groups at high risk for HIV
infection
• 3 rounds completed to-date
• Rounds consist of 3 cycles
– MSM
– IDU
– HET
• 6 city / 14 state health
departments

NHBS IDU4 Cycle
• Sample collection began July 2015
• Eligibility Requirements
– Present a valid NHBS-IDU coupon
– Have not previously participated in the current NHBS-IDU cycle
– Live in the participating MSA (Philadelphia, Montgomery, Delaware,
Chester, Bucks Counties)
– 18 years old or older
– Have injected drugs in the last 12 months
• N=645
– Goal: 500 interviews

Screening Process
with an NHBS
Interviewer
Eligible
Interview $25:
Risk Behavior Survey
Offered to be Recruiter:
Given Coupons to give
to give to people they
know to bring them
into the study
$10 per Recruit
Optional:
HIV Testing - INSTI $25
HCV Testing -ORAQUICK
Ineligible Nothing Further
Brief Overview of NHBS Process

Sample Characteristics
• Gender
– Male 74%
– Female 25%
– Transgender 1%
• Race
– White 66%
– Black 11%
– Hispanic 11%
– Multiracial 12%
– Asian <1%
– American Indian/Alaskan
Native <1%
– Native Hawaiian/Other
Pacific Islander <1%
 Age
 18-24 8%
 25-29 16%
 30-34 23%
 35-39 19%
 40+ 34%
 Region
 Kensington 42%
 Northeast Phila 19%
 North Phila 13%
 Center City 7%
 Outside Phila 5%
 South Phila 5%
 Other 9%

IDU3 IDU4
18-29 90 156
30+ 467 489
16%
24%
0
100
200
300
400
500
600
Particpants
Youth Sample Comparision
IDU3 to IDU4

HIV Preliminary Results
• IDU4 HIV Results
– 32 Positive Participants (5%)
• 19 Self-Reported as HIV positive
• IDU3 HIV Results (2012)
– 28 Positive Participants (5%)

HCV Results and Testing History
HCV Results
– 522 (81%) Reactive
• 169 Newly Dxed HCV
Infections
– 109 (17%) Non-reactive
– 2% Other
• Coinfection Rates
– 27 of the 32 HIV
reactive individuals also
reactive on the HCV
test
– 4% of total sample
 553(86%) had previously been
tested for HCV
 28% Public Health/Community
Health Center/Provider
 19% Correctional Facility
 15% Drug Treatment Program
 15% Needle or Syringe Exchange
Program
 5% Mobile/Street Outreach
 3% CTR site
 3% Family Planning /OB
 2% Don’t Know/Refused

Limitations
• Do not perform the confirmatory HCV test
– Unable to follow up to capture these results
– Unable to calculate linkage rates on a person level
• Survey sample may not be representative of
overall IDU population in Philadelphia
– Youth Population
– Female Population
– Hispanic Population

Kathleen Brady - HIV in Philadelphia (Annual Epidemiological Presentation)

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