Dr. Kathleen Brady's 2013 Epidemiologic Update

KATHLEEN A . BRADY, MDMEDICAL DIRECTOR/MEDICAL

EPIDEMIOLOGISTAIDS ACTIVITIES COORDINATING OFFICE

MARCH 27 , 2013

The HIV Engagement in Care Cascade

The Gardner Cascade

Engagement in Care

Gardner Stage of Engagement in HIV Care

Gardner Stage of Engagement in HIV Care

19% undetectab

le

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, 2009

HIV-In

fected

HIV-D

iagno

sed

Linke

d to C

are

In Car

e

On ART

Supp

resse

d vira

l load

0

5000

10000

15000

20000

25000 19188100% 15753

82% 1189462% 9944

52% 875146% 5775

30%

For every 100 people living with HIV:

USNumber

82 Are aware of their infection

66 Are linked to HIV care

37 Stay in HIV care

33 Get antiretroviral therapy

25Have a very low amount of virus in their body

PhiladelphiaNumber

82 Are aware of their infection

62 Are linked to HIV care

52 Stay in HIV care

46 Get antiretroviral therapy

30Have a very low amount of virus in their body

2009 Data

Who is Aware?


HIV-In

fected

HIV-D

iagno

sed

Linke

d to C

are

In Car

e

On ART

Supp

resse

d vira

l load

0

5000

10000

15000

20000

25000 19188100% 15753

82% 1189462% 9944

52% 875146% 5775

30%

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

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

HIV/AIDS Cases by Date of Diagnosis

11781302

1177

1001898

1200

894 895 907 861 821712 756

652

452

221 239176

940 918 921 893

729 712

1308

0200

400600

8001000

12001400

Year

Num

ber

of C

ases

AIDS HIV

21

HIV/AIDS Cases by Sex and Date of Diagnosis

0200400600800

1000120014001600

Year

Num

ber

of C

ases

AIDS Female AIDS Male HIV Female HIV Male

22

HIV Cases by Race/Ethnicity and Date of Diagnosis

171142 127 106 110

575 594534

479 498

133 146210

12795

0

100

200

300

400

500

600

700

2006 2007 2008 2009 2010 2011

Year

Num

ber

of C

ases

White AfrAm Hispanic

HIV diagnoses by risk group, 2007-2011

2007 2008 2009 2010 20110

100

200

300

400

500

600

MSM IDU HET

Demographics of new positives, MSM

New HIV diagnoses among MSM by race, 2007-2011

2007

2008

2009

2010

2011

Total

0%10%20%30%40%50%60%70%

Black Latino White

New HIV diagnoses among MSM by age, 2007-2011

2007

2008

2009

2010

2011

Total

0%10%20%30%40%50%60%

13 - 24 25 - 44 45+

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

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

Demographics of new positives, IDU2007 - 2011

70.1%

29.8%

Sex

MaleFemale

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

Demographics of new positives, HET2007 - 2011

50.7%49.2%

Sex

MaleFemale

Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMAEMATotal

N=2,221EMA

%

PhiladelphiaN=1,606

%

PA N=378

%

NJ N=237

%Race/EthnicityWhite, non-Hispanic 481 21.7 16.1 38.9 32.1Black, non-Hispanic 1,313 59.1 64.1 46.8 45.1Hispanic 372 16.7 17.8 10.0 20.3Asian/PI 3 0.2 1.2 2.4 2.1American Indian/Alaskan Native

41.5

0.20.0

0.0

Multi-Race 18 0.8 0.6 1.9 0.4Unknown 0 0.0 0.0 0.0 0.0GenderMale 1,634 73.6 73.6 74.6 71.7Female 587 26.4 26.4 25.4 28.3


N=2,221EMA

%

PhiladelphiaN=1,606

%

PA N=378

%

NJ N=237

%Age<13 years 13 0.6 .5 0.8 0.813 - 19 years 140 6.3 6.4 7.4 3.8 20 - 44 years 1,51 69.8 70.5 6.9 69.645+ years 517 23.3 22.5 24.9 25.7Mode of TransmissionMen who have sex with men 840 37.8 39.5 29.9 38.8Injection drug users 222 10.0 9.5 14.6 6.3Men 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 46.0Other/Hemophilia/blood transfusion

0 0.0 0.0 0.0 0.0

Perinatal Exposure 18 0.8 0.6 1.9 0.8Risk not reported or identified 192 8.6 9.5 10.1 0.8


N=2,221EMA

%

PhiladelphiaN=1,606

%

PA N=378

%

NJ N=237

%InsuranceMedicaid 411 18.5 23.1 0.0 16.9Private 414 18.6 21.9 0.0 26.6No Coverage 167 7.5 7.7 0.0 18.1Other Public Funding 305 13.7 18.4 0.0 3.8Unknown 924 41.6 28.9 100.0 34.6

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 increasingGrowing numbers of persons living with HIV

and AIDS25% decline in newly diagnosed AIDS

Who is unaware?


HIV-In

fected

HIV-D

iagno

sed

Linke

d to C

are

In Car

e

On ART

Supp

resse

d vira

l load

0

5000

10000

15000

20000

25000 19188100% 15753

82% 1189462% 9944

52% 875146% 5775

30%

Concurrent HIV/AIDS, 2010

Linkage to care


HIV-In

fected

HIV-D

iagno

sed

Linke

d to C

are

In Car

e

On ART

Supp

resse

d vira

l load

0

5000

10000

15000

20000

25000 19188100% 15753

82% 1189462% 9944

52% 875146% 5775

30%

Linkage to Care 2009-2010by 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

Linkage to Care 2009-2010by 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

Retention in care


HIV-In

fected

HIV-D

iagno

sed

Linke

d to C

are

In Car

e

On ART

Supp

resse

d vira

l load

0

5000

10000

15000

20000

25000 19188100% 15753

82% 1189462% 9944

52% 875146% 5775

30%

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 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

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)

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)

Calculated Results Value CalculationRow 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)

Unmet need by demographic groups, 2011

HIV AIDS0.0%5.0%

10.0%15.0%20.0%25.0%30.0%35.0%40.0%

33.6%

13.4%

27.4%

15.5%

31.8%

15.2%

Black WhiteHispanic

HIV AIDS0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

33.4%

15.2%

28.1%

10.6%

Male Female

Unmet need by insurance status, 2011

HIV AIDS0.0%5.0%

10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%50.0%

28.3%

13.5%

22.4%

12.6%

33.7%

7.5%

46.4%

29.6%

43.1%

26.6%

Medicaid Private Other publicUnknown None

Disparities


HIV-In

fected

HIV-D

iagno

sed

Linke

d to C

are

In Car

e

On ART

Supp

resse

d vira

l load

0

5000

10000

15000

20000

25000 19188100% 15753

82% 1189462% 9944

52% 875146% 5775

30%

Engagement in Care by Sex, 2009

Diagno

sed

In Car

e

On ART

Supp

resse

d0

2000

4000

6000

8000

10000

12000 82%

47% 43%35%

Male

Diagno

sed

In Car

e

On ART

Supp

resse

d0

1000

2000

3000

4000

5000

600082%

67%54%

35%

Female

Engagement in Care by Race/Ethnicity, 2009

Black White Hispanic0

2000

4000

6000

8000

10000

1200082%

82%82%

49%

54% 68%

42%

50% 60%

31%

45%39%

Diagnosed In Care On ART Suppressed

Engagement in Care by Mode of Transmission, 2009

MSM HET male HET female0

1000

2000

3000

4000

5000

6000 82%82% 4668

49%48%

64%46%

43%51%

39%32% 33%


Engagement in Care by Age Group, 2009

18-24 25-34 35-44 45-54 55+0

1000

2000

3000

4000

5000

6000


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

clinicaloptions.com/hivStarting 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%

•N

umbe

r of I

ndiv

idua

ls

•Current •DX90%

•Engage90%

•Treat90%

•VL < 50 in 90%

• Dx, Engage, Tx, and VL < 50

in 90%

Undiagnosed HIVNot linked to careNot retained in careART not requiredART not utilizedViremic on ARTUndetectable HIV-1 RNA

QUESTIONS?

The End

Dr. Kathleen Brady's 2013 Epidemiologic Update

Health & Medicine

Transcript of Dr. Kathleen Brady's 2013 Epidemiologic Update