HIV Care Continuum, Georgia, United States, 2011Presented to American Public Health Association, Annual Meeting

Presented by Deepali Rane, MBBS, MPH, Epidemiologist Date: 4th November, 2013

Presenter Disclosures

Deepali Rane

“No Relationships to Disclose”

Outline• Overview of HIV statistics Georgia statewide

• Define and describe the HIV care continuum methodology

• Describe the HIV care continuum for persons living with and new diagnoses of HIV infection

• Discuss the HIV care continuum in Georgia by demographic characteristics and transmission category

Epidemic of HIV infection, Georgia, 1995 to 2011

Late testers=Persons diagnosed with stage 3, AIDS within one year of HIV diagnosis

WHAT IS THE HIV CARE CONTINUUM ?

Georgia Care Continuum Methodology, Persons Living With HIV infection (PLWH), 2011

• 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 category• 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• Viral suppression (VS) = VL<200 copies/ml in most recent VL• All percentages are percent of total number of persons

diagnosed with HIV

Adults and adolescents living with HIV infection, Georgia, 2011

Series10

20

40

60

80

100100

54

38 39

Diagnosed Engaged Retained Viral suppression

Perc

ent

N=46,495

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 Note: All percentages are proportion of total number of persons living with HIV infection

Adults and adolescents living with HIV, by sex,

Georgia, 2011

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 Excludes 270 cases for whom sex was not reportedNote: All percentages are proportion of total number of persons living with HIV infection in each category

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, 2011

Black Hispanic/Latino White Other*/ Unknown0

20

40

60

80

100

54 51 55 57

36 3542 4036 37

45 43

Diagnosed Engaged Retained 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/ethnicityNote: All percentages are proportion of total number of persons living with HIV infection in each category

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

Georgia, 2011

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 Note: All percentages are proportion of total number of persons living with HIV infection in each category

Adult and adolescent males living with HIV,

by transmission category*, Georgia, 2011

MSM IDU MSM/IDU HET Other0

20

40

60

80

100

56

4352 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/ml*Multiple imputation is used to estimate number of persons in each transmission category. Note: All percentages are proportion of total number of persons living with HIV infection in each category

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

Georgia, 2011

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 categoryNote: All percentages are proportion of total number of persons living with HIV infection in each category

Georgia Care Continuum Methodology, New Diagnoses of HIV infection, Georgia, 2011

• Adults and adolescents are those aged >= 13 years• Diagnosed between 01/01/11 -12/31/11• Alive at least 15 months after diagnosis• Residence at diagnosis and current address within

Georgia• Excludes 52 persons deceased within 15 months of diagnosis• Linked to care = CD4 or VL within 3 months of

diagnosis , excluding date of diagnosis• Engaged in care >= 1 CD4 or VL 4-15 months after

diagnosis• Retained in care >= 2 CD4 or VL at least 3 months

apart 4-15 months after diagnosis• Viral suppression (VS) = VL<200 copies/ml in most recent

viral load• All percentages are percent of total number of persons

diagnosed with HIV

HIV Care Continuum Methodology

Confirmatory Diagnosis

Date

Months 0-3 after diagnosis

Months 4-15 after diagnosis

CD4 or Viral Load

CD4 or Viral Load

CD4 or Viral Load

This person is:• Linked YES• Engaged YES • Retained YES• Virally suppressed YES

Last viral load <200 copies/ml

Adults and adolescents diagnosed with HIV infection, Georgia, 2011

Diagnosed only0

102030405060708090

100100

6266

46 45

DiagnosedLinked to careEngaged in careRetained in careViral sup-pression

Perc

en

t

Adults and adolescents >= age 13, diagnosed 01/01/11 -12/31/11, Georgia = 2,885Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral suppression (VS) = VL<200 copies/ml in most recent viral load = 1307Note: All percentages are proportion of total number of persons diagnosed with HIV

Adults and adolescents diagnosed with HIV infection, by sex, Georgia,

2011

Males Females0

20

40

60

80

100

616665 67

46 4544 48

Diagnosed Linked to care Engaged in care Retained in care Viral suppression

Perc

en

t

Adults and adolescents>= age 13, diagnosed 01/01/11 - 12/31/11, Georgia =2,869Excludes 16 persons for whom sex was not reported Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral suppression (VS) = VL<200 copies/ml in most recent viral load Note: All percentages are proportion of total number of persons diagnosed with HIV infection in each category

N=2,214 N=655

Adults and adolescents diagnosed with HIV infection, by race/ethnicity,

Georgia, 2011

Black Hispanic/Latino White Other/unknown0

102030405060708090

100

62

72 71

5765

70 7364

4453 54

4538

56 54 54

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

en

t

N=1,616 N=144 N=271 N=854

Adults and adolescents >= age 13, diagnosed 01/01/11 - 12/31/11, Georgia = 2,885Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral suppression (VS) = VL<200 copies/ml in most recent viral load Other/Unknown include American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islanders and equal <2% of new diagnosesNote: All percentages are proportion of total number of persons diagnosed with HIV infection in each category

Adults and adolescents diagnosed with HIV infection, by age (years), Georgia,

2011

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

20

40

60

80

100

57 5965 68 67

62 66 67 6964

3946 47

5247

3443

50 54 52

Diagnosed Linked to care Engaged in care Retained in care

Perc

en

t

Adults and adolescents >= age 13, diagnosed 01/01/11 - 12/31011, Atlanta = 2,885Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral suppression (VS) = VL<200 copies/ml most recent viral load Note: All percentages are proportion of total number of persons diagnosed with HIV infection in each category

N=655 N=786 N=649 N=537 N=258

Adult and adolescent males diagnosed with HIV infection,

by transmission category*, Georgia, 2011

MSM IDU MSM/IDU HET Other0

20

40

60

80

100

6167 67

75

5865

6067 71

65

46 44 42 45 4839 40 39

4858

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

en

t

N=1386 N=36N=68 N=101 N=623

Adult and adolescent males >= age 13, diagnosed 01/01/11 - 12/31/11, Georgia = 2214Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral suppression (VS) = VL<200 copies/ml in most recent viral load *Multiple imputation was used to re-distribute transmission category where missingNote: All percentages are proportion of total number of persons diagnosed with HIV infection in each category

Adults and adolescent females diagnosed with HIV infection, by transmission category*,

Georgia, 2011

IDU HET Other0

102030405060708090

100

7571

50

74 71

5552 50

32

5450

42

Diagnosed Linked to care Engaged in care Retained in care Viral suppression

Perc

en

t

Adults and adolescent females >= age 13, diagnosed 01/01/11 - 12/31/11, Georgia = 655Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral suppression (VS) = VL<200 copies/ml in most recent viral load *Multiple imputation was used to re-distribute transmission category where missingNote: All percentages are proportion of total number of persons diagnosed with HIV infection in each category

N=81 N=411 N=163

The HIV Care Continuum can help…

• 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 facilities

• Encourage improvement in surveillance data completeness (race, sex, transmission category)

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

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

Questions?

Contact information:Deepali Rane, MBBS, MPHderane@dhr.state.ga.usGeorgia Department of Public HealthHIV/AIDS Epidemiology ProgramSuite 14-4662 Peachtree St NWAtlanta GA 30303404-657-2600

For more information on HIV Surveillance, Georgia, visithttp://dph.georgia.gov/georgias-hivaids-epidemiology-surveillance-section

For information on HIV Prevention, Georgia visithttp://dph.georgia.gov/hiv-prevention-program