HIV Care ContinuumPersons Living With HIV,

Georgia, 2012

Diagnose

d

Linke

d to ca

re

Retained in

care

Prescribed ART

Viral S

uppression

0102030405060708090

100

Persons with HIV Engaged in Selected Stages of the Continuum of Care, United States

Perc

ent

82

66

37 3325

Hall et al. XIX International AIDS Conference, 2012ART, antiretroviral therapy

Georgia Care Continuum Methodology, Persons Living With HIV (PLWH), 2012

• Adults and adolescents are those aged >= 13 years• Diagnosed by 09/30/2011 (Western Blot or Viral Load [VL]) ,

including those missing race, sex, and/or transmission risk• Living as of 12/31/2012• Current address within Georgia• Engaged in care >= 1 CD4 or VL in 2012• Retained in care (>= 2 CD4 or VL at least 3 months apart in

2012• Estimated percentage prescribed ART derived from the

Medical Monitoring Project (MMP) Georgia sample • Viral suppression (VS) = VL<200 copies/ml in most recent VL• All percentages are percent of total number of persons

diagnosed with HIV

Special consideration: linkage to care within 3 months for prevalent population

• HIV reporting began in Georgia 2004; CD4 and viral load (VL) measurements are not available before this date

• Linkage to care proxy is CD4 or VL within 3 months of diagnosis date

• Linkage is missing for 54% of Georgia’s prevalent HIV population and therefore not represented here

• Linkage to care data are included in the New Diagnoses 2011 slide set for persons diagnosed in 2011

Special Consideration: people living with HIV, diagnosed in 2011

• Linkage to care = CD4 or VL within 3 months of diagnosis

• For persons diagnosed in 2011, the first CD4 or VL represents linkage to care

• CD4 or VL within the first 3 months of diagnosis is excluded from the engagement and retention in care measurements

• To allow 12 months for engagement and retention in care and viral suppression, only persons diagnosed by 09/30/2011 and followed through 12/31/12 are included

Adults and adolescents living with HIV, Georgia, 2012

Diagnosed only Including estimated undiagnosed0

20

40

60

80

100100

82

5444

383134

2839

32

Diagnosed Engaged Retained ART Viral suppression

Perc

en

t

N=46,495 N=56,701

Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 46,495Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Prescribed ART derived from MMP sample Viral suppression (VS) = VL<200 copies/ml Estimated undiagnosed based on CDC projections for proportion undiagnosed nationally

Adults and adolescents living with HIV, by sex,

Georgia 2012

Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012 Georgia = 46,495Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Prescribed ART derived from MMP sample Viral suppression (VS) = VL<200 copies/ml Excludes 270 cases for whom sex was not reported

Male Female0

20

40

60

80

100

54 55

38 3739 38

Diagnosed Engaged Retained Viral suppression

Perc

en

t

N=34,510 N=11,715

Adults and adolescents living with HIV, by race/ethnicity, Georgia, 2012

Black Hispanic/Latino White Other*/ Unknown

0

20

40

60

80

100

54 51 55 57

36 3542 4036 37

45 43

Diagnosed EngagedRetained Viral suppression

Perc

en

t

N= 30,150 N= 2,282 N= 9,382 N= 4,681

Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 46,495Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml *American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of adults living with HIV in Georgia and are grouped with those of mixed or unknown race/ethnicity

Adult and adolescent males living with HIV, by race/ethnicity, Georgia

2012

Black Hispanic/Latino White Other*/ Unknown

0

20

40

60

80

100

53 5056 60

36 3443 43

35 3746 46

Diagnosed Engaged Retained Viral suppression

Perc

en

t

N= 21,178 N= 8,071 N= 1,784 N= 3,477

Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 34,510Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml *American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of males living with HIV in Georgia and are grouped with those of mixed or unknown race/ethnicity

Adult and adolescent females living with HIV, by race/ethnicity, Georgia

2012

Black Hispanic/Latino

White Other*/ Unknown

0

20

40

60

80

100

57 53 51 5138 38 33 3338 40 38 35

Diagnosed Engaged Retained Viral suppression

Perc

en

t

Adult and adolescent females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 11,715Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <1% of adults living with HIV in Georgia and are grouped with those of mixed or unknown race/ethnicity

N= 8,926 N= 492 N= 1303 N= 994

Adults and adolescents living with HIV by current age (years),

Georgia 2012

13-24 25-34 35-44 45-54 55+0

102030405060708090

100

5853 56 56

50

35 3338 40 37

30 3139 42 40

Diagnosed EngagedRetained Viral suppression

Perc

en

t

N= 1,814 N= 7,789 N= 11,665 N= 15,915 N= 9,312

Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 46,495Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml

Adult and adolescent males living with HIV by current age (years),

Georgia 2012

13-24 25-34 35-44 45-54 55+0

20

40

60

80

100

57 54 56 5648

33 34 39 41 3728 31

40 43 39

Diagnosed EngagedRetained Viral suppression

Perc

en

t

N= 1,336 N= 5,866 N=12,130N= 8,316 N=6,862

Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 34,510Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml

Adult and adolescent females living with HIV by current age

(years),Georgia 2012

13-24 25-34 35-44 45-54 55+0

102030405060708090

100

6150

55 57 56

43

31 35 38 393528

3641 43

Diagnosed Engaged in careRetained Viral suppression

Perc

en

t

N= 468 N= 1,856 N= 3,265 N= 3,712 N= 2,414

Adult and adolescent females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 11,715Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml

Transmission category definitions

• Multiple imputation was used to re-distribute transmission category where missing

• MSM = Male to male sexual contact• IDU = Injection drug use• MSM/IDU = Male to male sexual contact and injection drug

use• HET = Heterosexual contact with a person known to have, or

to be at high risk for, HIV infection• Other = hemophilia, blood transfusion, perinatal exposure,

and risk factor not reported or not identified

Adult and adolescent males living with HIV, by transmission category,

Georgia 2012

MSM IDU MSM/IDU HET Other0

20

40

60

80

100

5643

52 53 55

3931

37 34 394031 36 37 42

Diagnosed Engaged Retained Viral suppression

Perc

en

t

N= 24,935 N= 2,583 N= 2,428N= 2,022 N= 2,541

Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 34,510Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/mlMultiple imputation is used to estimate number of persons in each transmission category. *MSM = Male to male sexual contact IDU = Injection drug useMSM/IDU = Male to male sexual contact and injection drug useHET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infectionOther = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

Adult and adolescent females living with HIV, by transmission category,

Georgia 2012

HET IDU Other0

20

40

60

80

100

57 5445

37 3731

39 3731

Diagnosed EngagedRetained Viral suppression

Perc

en

t

N= 8,420 N= 2,452 N= 842

Adult and adolescent females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 11,715Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml Multiple imputation is used to estimate number of persons in each transmission category. *IDU = Injection drug useHET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infectionOther = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

Black MSM* living with HIV, by current age (years), Georgia

2012

13-24 25-34 35-44 45-54 55+0

20

40

60

80

100

55 54 57 5549

29 33 38 40 3725 30

38 40 39

Diagnosed Engaged Retained Viral suppression

Perc

en

t

N= 940 N= 3,968 N= 4,718N= 4,146 N= 1886

Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 15,657Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/mlMultiple imputation is used to estimate number of persons in each transmission category. *MSM = Male to male sexual contact IDU = Injection drug useMSM/IDU = Male to male sexual contact and injection drug useHET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infectionOther = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

White MSM* living with HIV, by current age (years), Georgia 2012

13-24 25-34 35-44 45-54 55+0

20

40

60

80

100

60 56 60 56 5139 40 43 44 42

35 3947 47 45

Diagnosed Engaged Retained Viral suppression

Perc

en

t

N= 82 N= 592 N= 3,622N= 1,732 N= 2,043

Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 8,071Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/mlMultiple imputation is used to estimate number of persons in each transmission category. *MSM = Male to male sexual contact IDU = Injection drug useMSM/IDU = Male to male sexual contact and injection drug useHET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infectionOther = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

Hispanic/Latino MSM* living with HIV, by current age (years), Georgia 2012

13-24 25-34 35-44 45-54 55+0

20

40

60

80

100

6353

47 524644

34 3038 33

4435 34

40 36

Diagnosed Engaged Retained Viral suppression

Perc

en

t

N= 52 N= 355 N= 559N= 607 N= 97

Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 1,670Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/mlMultiple imputation is used to estimate number of persons in each transmission category. *MSM = Male to male sexual contact IDU = Injection drug useMSM/IDU = Male to male sexual contact and injection drug useHET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infectionOther = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

The HIV Care Continuum can help us…

• Focus our efforts for linkage, retention and viral suppression.• Identify groups at increased risk for dropping out of each

step in the continuum.• Monitor our progress in improvement of linkage, retention,

and viral suppression.• Identify disparities not only in prevalence but in care• Evaluate efforts addressing specific populations with low

viral suppression.• Monitor efforts in improving viral suppression in specific

counties, census tracts, zip codes and some specific facilities• Encourage improvement in surveillance data completeness

(race, sex, transmission category)

Viral suppression (VS) among adults and adolescents engaged

and retained in care, by sex, Georgia 2012

Male Female Unknown sex0

102030405060708090

100

72 687878 75

86

VS among engaged VS among retained

Perc

en

t

*N= number retained in careAdults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml

N* = 13,160 N* = 4,298 N* = 71

Viral suppression (VS) among adult and adolescent males engaged and retained in

care, by race/ethnicity, Georgia 2012

Black Hispanic/Latino

White Other*/Unknown

0102030405060708090

100

6673

837773

7987 83

VS among engaged VS among retained

Perc

en

t

*N= number retained in careAdult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml*American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of males living with HIV in Georgia and are grouped with those of mixed or unknown race/ethnicity

N* = 11,236 N* = 893 N* =4,490 N* =2,078

Viral suppression (VS) among adult and adolescent females engaged and retained

in care, by race/ethnicity, Georgia 2012

Black Hispanic/Latino

White Other*/Unknown

0

20

40

60

80

100

6776 73 7074

81 79 78

VS among engaged VS among retained

Perc

en

t

*N= number retained in careAdult and adolescent females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, GeorgiaEngaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml*American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of males living with HIV in Georgia and are grouped with those of mixed or unknown race/ethnicity

N* = 186N* = 3,350 N* = 432 N* = 330

Viral suppression (VS) among adults and adolescents engaged and

retained in care, by current age (years), Georgia 2012

13-24 25-34 35-44 45-54 55+0

102030405060708090

100

5158

6976 80

5866

7681

86

VS among engaged VS among retained

Perc

en

t

*N= number retained in careAdult and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml

N* = 639 N* = 2,568 N* = 7,265 N* = 3,486N* = 6,436

Viral suppression (VS) among adult and adolescent males engaged and retained

in care, by current age (years), Georgia 2012

13-24 25-34 35-44 45-54 55+0

102030405060708090

100

4958

7077 81

5766

7782

87

VS among engaged VS among retained

Perc

en

t

*N = number retained in careAdult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml

N* = 436 N* = 1,987 N* = 3,223 N* 4,992 N* = 2,522

Viral suppression (VS) among adult and adolescent females engaged and retained

in care, by current age (years), Georgia 2012

13-24 25-34 35-44 45-54 55+0

102030405060708090

100

57 5666

7277

62 6473

7883

VS among engaged VS among retained

Perc

en

t

*N= number retained in careAdult and adolescent females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia Engaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml

N* = 200 N* = 570 N* = 1,157 N* = 1,149 N* = 952

Viral suppression (VS) among adult and adolescent males engaged and retained in

care, by transmission category**, Georgia 2012

MSM IDU MSM/IDU HET Other0

20

40

60

80

100

71 73 70 717778 80 78 78 83

VS among engaged VS among retained

Perc

en

t

*N= number retained in care; Males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, GeorgiaEngaged in care >= 1 CD4 or VL in 2012; Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml**MSM = Male to male sexual contact IDU = Injection drug useMSM/IDU = Male to male sexual contact and injection drug useHET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infectionOther = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

N* = 9,787 N* = 801 N* = 741 N* = 830 N* 1,001

Viral suppression (VS) among adult and adolescent females engaged and retained

in care, by transmission category**, Georgia 2012

HET IDU Other0

102030405060708090

100

68 68 7075 76 79

VS among engaged VS among retained

Perc

en

t

*N= number retained in care; Females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, GeorgiaEngaged in care >= 1 CD4 or VL in 2012; Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml**HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infectionIDU = Injection drug useOther = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

N* = 3,129 N* = 907 N*= 262

Viral suppression (VS) among Black MSM engaged and retained in care,

by current age (years), Georgia 2012

13-24 25-34 35-44 45-54 55+0

20

40

60

80

100

4455

6672

79

5163

73 7784

VS among engaged VS among retained

Perc

en

t

*N= number retained in careAdult and adolescent Black MSM >= age 13, diagnosed by 09/30/2011, living 12/31/2012, GeorgiaEngaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml

N* = 670 N* = 2,658 N* = 344 N* = 136 N* = 68

Viral suppression (VS) among White MSM engaged and retained in care,

by current age (years), Georgia 2012

13-24 25-34 35-44 45-54 55+0

102030405060708090

100

58

7279

8590

6876

85 88 92

VS among engaged VS among retained

Perc

en

t

*N= number retained in care Adult and adolescent White MSM >= age 13, diagnosed by 09/30/2011, living 12/31/2012, GeorgiaEngaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml

N* = 39 N* = 319 N* = 849 N* = 136 N* = 68

Viral suppression (VS) among Hispanic/Latino MSM engaged and

retained in care, by current age (years), Georgia 2012

13-24 25-34 35-44 45-54 55+0

102030405060708090

100

68 6572

77 807971

7682

91

VS among engaged VS among retained

Perc

en

t

*N= number retained in careAdult and adolescent H/L MSM >= age 13, diagnosed by 09/30/2011, living 12/31/2012, GeorgiaEngaged in care >= 1 CD4 or VL in 2012Retained in care >= 2 CD4 or VL at least 3 months apart in 2012Viral suppression (VS) = VL<200 copies/ml

N* = 23 N* = 200 N* = 344 N* = 253 N* = 74

Viral suppression (VS) among adults and adolescents engaged in care, Georgia, 2012, by diagnosis year

2000200120022003200420052006200720082009201020110

102030405060708090

100

81 79 81 79 78 74 75 76 74 73 74 72

VS among engaged

Year of diagnosis

Perc

en

t

Adults and adolescent s >= age 13, living 12/31/2012, current address Georgia = 46,495Engaged in care >= 1 CD4 or VL in 2012Viral suppression (VS) = VL<200 copies/ml

Limitations

• Incomplete reporting • Missing data for race/ethnicity, sex, and current

address • Lack of transmission category information• Multiple imputation use to redistribute risk when

missing• Definition of heterosexual transmission (sexual

contact with a known HIV infected partner or person with increased risk, i.e., MSM or IDU)

• Missing laboratory reports may lead to underestimation of engagement, retention and viral suppression

• Cannot distinguish lack of prescription of ART, failure of ART adherence, or inappropriate medication choice

• Laboratory measures may be a poor proxy for engagement and retention in HIV care

Future analyses

• Monitoring the Care Continuum for both the prevalent population and by new diagnoses by year

• Advantages of monitoring the Care Continuum for new diagnoses: – Can measure linkage to care for new diagnoses– Excludes older cases who may have moved out of

state– May be more sensitive for measuring

effectiveness of interventions to improve testing, linkage, engagement and retention in care

– Can measure time from diagnosis to viral suppression

Uncertainties

• Populations for which data are missing may be fundamentally different

• How to obtain data for transgender category• How to improve completeness of reporting• Data on ART use difficult to capture• Understanding barriers to ART adherence• Prioritizing further research

FOR MORE INFORMATION CONTACT:

Georgia Department of Public HealthHIV/AIDS Epidemiology Programhttp://health/state.ga.us/epi/hivaids