kathleen brady - hiv in philadelphia (annual epidemiological presentation)
TRANSCRIPT
HIV in Philadelphia
Kathleen A. Brady, MDMedical Director/Medical Epidemiologist
AIDS Activities Coordinating OfficePhiladelphia Department of Public Health
From Bench to Bus StopJanuary 26, 2016
THE HIV CARE CONTINUUM
HIV Care Continuum
Adapted from Eldred et al AIDS Patient Care STDs 2007;21(Suppl1):S1-S2Cheever 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:
National HIV Surveillance System 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:
National HIV Surveillance System 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 20140
10
20
30
40
50
60
70
80
90
100
Philadelphia HIV Linkage by YearPe
rcen
tage
(%)
*Significant increase in linkage within 30 days between 2010 and 2014 (p=0.02)Source: PDPH, AIDS Activities Coordinating Office, 2015
2011 2012 2013 20140
10
20
30
40
50
60
70
80
90
100
Philadelphia Care Continuum MeasuresPe
rcen
tage
(%)
*Significant increase between 2011 and 2014 (p<0.0001)Source: PDPH, AIDS Activities Coordinating Office, 2015
US (2012 Data) Philadelphia (2014 Data
Number
100 Diagnosed
80 Are linked to HIV care
54 Stay in HIV care
50 Get antiretroviral therapy
42Have 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
53Have a very low amount of virus in their body
For every 100 people living with HIV:
Source: PDPH, AIDS Activities Coordinating Office, 2015
NEW HIV DIAGNOSES
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
EMATotal
N=2,120
EMA
%
PhilaN=1,433
%
PA N=391
%
NJ N=224
%Race/EthnicityWhite, non-Hispanic 409 19.3 13.0 38.9 23.6Black, non-Hispanic 1,335 63.0 70.1 45.3 52.0Hispanic 307 14.5 14.1 10.0 22.3Asian/Pacific Islander 30 1.4 1.6 1.8 0.0American Indian/Alaskan Native
9 0.4 0.6 0.3 0.0
Multi-Race 24 1.1 0.6 3.8 0.0Unknown 6 0.3 0.0 0.0 2.0GenderMale 1,641 76.2 78.3 79.0 70.9
Newly Diagnosed HIV (Non-AIDS) for 2012-2014, Philadelphia EMA
EMATotal
N=2,120
EMA
%
PhilaN=1,433
%
PA N=391
%
NJ N=224
%Age<13 years 12 0.6 0.1 1.3 1.713 - 19 years 126 5.9 6.8 4.9 3.420-24 years 442 20.8 22.7 17.9 15.525-29 years 365 17.2 18.1 15.6 15.230-39 years 435 20.5 19.7 20.5 24.740-49 years 370 17.5 16.7 17.9 20.650+ years 370 17.5 15.9 22.0 18.9
Newly Diagnosed HIV (Non-AIDS) for 2012-2014, Philadelphia EMA
EMATotal
N=2,120
EMA
%
PhilaN=1,433
%
PA N=391
%
NJ N=224
%Mode of TransmissionMen 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 0.7Heterosexuals 786 37.1 37.5 33.5 39.9Other/hemophilia/blood transfusion
0 0.0 0.0 0.0 0.0
Perinatal exposures 15 0.7 0.3 1.3 1.7Risk not reported or identified
107 5.0 2.1 9.0 14.2
Newly Diagnosed HIV Cases, Deaths, and Living HIV Cases by YearPhiladelphia, 2008-2014
2008 2009 2010 2011 2012 2013 20140
200
400
600
800
1000
1200
1400
1600
1800
2000
15000
15500
16000
16500
17000
17500
18000
18500
19000
19500
20000
928 897739 680 729 679 624
524 511 546 473 432 393
165*
18640
1923719525
19157
1983219564 19494
Newly Diagnosed Deaths Living HIV Cases
*Data incomplete due to reporting delays
Source: PDPH, AIDS Activities Coordinating Office, 2015
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%
Mode of Transmission
MSM IDU HETMSM/IDU Pediatric NIR
Source: PDPH, AIDS Activities Coordinating Office, 2015
19
HIV/AIDS Cases by Date of Diagnosis
10861020
939862
763 779672
745 800 744 694 695 659521
424333 297 257 257
186 159
530 546 565 578442 423 472 493 465
1266
0200
400600
8001000
12001400
Year
Num
ber
of C
ases
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
Num
ber
of C
ases
HIV Female HIV Male
Newly Diagnosed HIV Disease by Race/Ethnicity (regardless of HIV status)
105 9773 90
479 501 503
422
87110
80 910
100
200
300
400
500
600
2010 2011 2012 2013 2014
Year
Num
ber
of C
ases
White AfrAm Hispanic
22
Newly Diagnosed HIV Disease by Mode of Transmission (regardless of AIDS status)
281297
5169
35 34
274
11 12
319352
254
324324
299
050
100150200250300350400
2010 2011 2012 2013 2014
Year
Num
ber
of C
ases
MSM IDU HetSx NIR
Newly Diagnosed HIV Disease by Age at Diagnosis(regardless of HIV status)
39 32
219
265251
211
138
126111
127 133120
136
3243
134146149152
159
112
0
50
100
150
200
250
300
2010 2011 2012 2013 2014
Year
Num
ber
of C
ases
13-19 20-29 30-39 40-49 50+
Newly Diagnosed HIV Cases, Deaths, and Living HIV Cases by YearPhiladelphia, 2008-2014
2008 2009 2010 2011 2012 2013 20140
200
400
600
800
1000
1200
1400
1600
1800
2000
15000
15500
16000
16500
17000
17500
18000
18500
19000
19500
20000
928 897739 680 729 679 624
524 511 546 473 432 393
165*
18640
1923719525
19157
1983219564 19494
Newly Diagnosed Deaths Living HIV Cases
*Data incomplete due to reporting delays
Source: PDPH, AIDS Activities Coordinating Office, 2015
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
Black Males Hispanic Males
Black Females
White Males Hispanic Females
White Females
-1.0%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
2.9%
2.2%
1.1% 1.1%0.8%
0.2%
Overall Prevalence 1.3%
Epidemic Level 1.0%
Source: PDPH, AIDS Activities Coordinating Office, 2015
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%
Mode of Transmission
MSM IDU HETMSM/IDU Pediatric NIR
Source: PDPH, AIDS Activities Coordinating Office, 2015
2013 Local Estimate of HIV Incidence
• Local estimate of 508 new HIV infections in 2013 in adults and adolescents (95% CI, 333-683)
Source: PDPH, AIDS Activities Coordinating Office, 2015
HIV Incidence Trends by Demographic Groups
0
200
400
600
800
1000
1200
2006 2007 2008 2009 2011 2012 2013
TotalAge 13-24MaleBlackMSM
Source: PDPH, AIDS Activities Coordinating Office, 2015
Estimated Incidence Rates - 2013
Population Population in 2010 (13 +)ESTIMATED
Incidence Estimate, 2013
EstimatedCase Rate per 100,000
95% CI lower bound
95% CI upper bound
MSM 29,737 324 1,089.6 632.2 1,550.3IDU 37,378 18 48.2 0 136.4HET 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)SexFemale 7.5% (0.9 %-14.1%)Male 11.5% (6.7%-15.4%)
Race/EthnicityBlack 12.5% (8.4%-17.0%)Hispanic 9.6% (1.4%-17.5%)White/Other 4.7% (0.1%-11.1%)
Mode of TransmissionHeterosexual 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%)Source: PDPH, AIDS Activities Coordinating Office, 2015
Non-Concurrent and Concurrent HIV/AIDS Among Incident HIV Diagnosis 2014 (EMA) Non-Concurrent Concurrent
HIV/AIDS TotalN Row % N Row % N Col %
Total 739 72.9% 227 24.8% 917 100%SexMale 579 81.4% 169 23.8% 711 77.5%Female 160 77.7% 58 28.2% 206 22.5%Race/EthnicityBlack 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%
Non-Concurrent and Concurrent HIV/AIDS Among Incident HIV Diagnosis 2014 (EMA) Non-Concurrent Concurrent
HIV/AIDS TotalN Row % N Row % N Col %
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%
Non-Concurrent and Concurrent HIV/AIDS Among Incident HIV Diagnosis 2014 (EMA)
Non-Concurrent Concurrent HIV/AIDS Total
N Row % N Row % N Col %Transmission RiskMSM 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 AreaPhiladelphia 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%
SPECIAL POPULATIONS
HIV CARE CONTINUUM BY RESIDENCE IN GEOGRAPHIC HOTSPOTS
Kathleen A. Brady, MD37
Diagnosed Linked to Care Retained in Care Virally Suppressed0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
100.0%
64.6%
33.0%26.3%
100.0%
54.3%
24.0%
9.1%
Not a Hotspot Hotspot
p < .05
p < .05 p
< .05
N=1,704
Source: PDPH, AIDS Activities Coordinating Office, 2015
Percent Retained, Using ART and Virally Suppressed
Source: PDPH, AIDS Activities Coordinating Office, 2015
Overall Transgender0
10
20
30
40
50
60
70
80
90
100
2014 Care Continuum Measures: TransgenderPe
rcen
tage
(%)
Source: PDPH, AIDS Activities Coordinating Office, 2015
Philadelphia HIV Care Continuum 2014
Diagnosed Engaged in Care Prescribed ART Virally Suppressed0%
10%20%30%40%50%60%70%80%90%
100%90%
47%
68%
48%
87%
44%
63%47%
87%
44%
66%
48%
ALL PLWHA MSM of Color Black MSMHispanic MSM Other MSM of Color White MSM
Source: PDPH, AIDS Activities Coordinating Office, 2015
NHBS-IDU4
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
Source: PDPH, AIDS Activities Coordinating Office, 2015
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
Source: PDPH, AIDS Activities Coordinating Office, 2015
Screening Process with an NHBS Interviewer
EligibleInterview $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
Source: PDPH, AIDS Activities Coordinating Office, 2015
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%
Source: PDPH, AIDS Activities Coordinating Office, 2015
IDU3 IDU40
100
200
300
400
500
600
16%
24%
Youth Sample Comparision IDU3 to IDU4
Parti
cpan
ts
Source: PDPH, AIDS Activities Coordinating Office, 2015
HIV Preliminary Results
• IDU4 HIV Results – 32 Positive Participants (5%)
• 19 Self-Reported as HIV positive
• IDU3 HIV Results (2012)– 28 Positive Participants (5%)
Source: PDPH, AIDS Activities Coordinating Office, 2015
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
Source: PDPH, AIDS Activities Coordinating Office, 2015
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
Source: PDPH, AIDS Activities Coordinating Office, 2015
Questions