dr. kathleen brady's 2013 epidemiologic update
TRANSCRIPT
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?
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%
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
Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMAEMATotal
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
Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMAEMATotal
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?
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%
Concurrent HIV/AIDS, 2010
Concurrent HIV/AIDS, 2010
Linkage to care
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%
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
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%
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
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%
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%
Diagnosed In Care On ART Suppressed
Engagement in Care by Age Group, 2009
18-24 25-34 35-44 45-54 55+0
1000
2000
3000
4000
5000
6000
Diagnosed In Care On ART Suppressed
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