multiple imputation for transmission category and the care continuum georgia, 2012
DESCRIPTION
Multiple Imputation for Transmission Category and the Care Continuum Georgia, 2012. Adults and adolescents living with HIV, Georgia , 2012. Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 46,495 Engaged in care >= 1 CD4 or VL in 2012 - PowerPoint PPT PresentationTRANSCRIPT
Multiple Imputation for Transmission Category and the Care Continuum
Georgia, 2012
Adults and adolescents living with HIV, Georgia, 2012
Diagnosed only 0
20
40
60
80
100100%
54%
38% 34% 39%
Diagnosed Engaged Retained ART Viral suppression
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 2012Prescribed ART derived from MMP sample Viral suppression (VS) = VL<200 copies/ml Estimated undiagnosed based on CDC projections for proportion undiagnosed nationally
Transmission category definitions
• 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
Multiple Imputation• Multiple imputation (MI) methods are used to
assign transmission categories to those persons whose diagnoses are reported without a risk factor
• MI is a statistical approach in which missing transmission categories are replaced with plausible values
• CDC uses MI for the national HIV dataset*• Georgia uses the same methodology as CDC
*Harrison KM, Kajese T, Hall HI, Song R. Risk factor redistribution of the national HIV/AIDS surveillance data: an alternative approach. Public Health Rep 2008;123:618–27.
More details on MI• MI draws a random sample of missing values• Then, MI replaces each missing value with a
set of values according to the relationship with other variables
• These multiply-imputed datasets are analyzed
• Final estimates are made based on these results
• MI is considered a sound approach and the best choice for large datasets*
* Rubin DB. Multiple imputation for nonresponse in surveys. New York: John Wiley & Sons; 1987.
Assumptions used in MI
• The distribution of risk factors among cases initially submitted with no reported risk factor (NRR) does not change during the period used in calculating weights
• Cases reclassified as NRR are representative of all NRR cases
• The data are missing at random
Adult and adolescent males living with HIV, by transmission category with multiple imputation, Georgia
2012
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/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 males living with HIV, by transmission category,
no multiple imputation, Georgia 2012
MSM IDU MSM/IDU HET Other0
20
40
60
80
100
57
3951 52 53
4129
3732 36
4129
36 36 38
Diagnosed Engaged Retained Viral suppression
Perc
en
t
N= 17,533 N= 1.739 N= 1,580N= 1,490 N= 12,168
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*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 with
multiple imputation, 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
Adult and adolescent females living with HIV, by transmission category, no
multiple imputation, Georgia 2012
HET IDU Other0
20
40
60
80
100
55 51 56
35 34 383933 38
Diagnosed EngagedRetained Viral suppression
Perc
en
t
N= 3,048 N= 1,056 N= 7,611
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 *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 age (years), with multiple imputation,
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= 1,083 N= 4,307 N= 6,796N= 4,977 N= 1,824
Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 18,987Engaged 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
Black MSM living with HIV, by age (years), no multiple imputation,
Georgia 2012
13-24 25-34 35-44 45-54 55+0
20
40
60
80
100
60 58 59 5649
32 36 41 42 3827 32
40 41 40
Diagnosed Engaged Retained Viral suppression
Perc
en
t
N= 644 N= 2,729 N= 3,115N= 2,786 N= 1,127
Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 10,401Engaged 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 age (years), with multiple imputation,
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
White MSM living with HIV, by age, no multiple imputation, Georgia 2012
13-24 25-34 35-44 45-54 55+0
20
40
60
80
100
6757 61 57
494739
45 45 4242 4048 49 45
Diagnosed Engaged Retained Viral suppression
Perc
en
t
N= 43 N= 370 N= 2,507N= 1,182 N= 42
Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 4,144Engaged 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 age (years), with multiple imputation,
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
Hispanic/Latino MSM living with HIV, by transmission category, no multiple
imputation, Georgia 2012
13-24 25-34 35-44 45-54 55+0
20
40
60
80
100
7163
56 54 545042 38 40 4243 42 41 41 43
Diagnosed Engaged Retained Viral suppression
Perc
en
t
N= 28 N= 192 N= 286N= 328 N= 72
Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 906Engaged 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
Conclusions• Overall, the Care Continuum varied little whether
MI is or is not used in the Georgia 2012 estimates • Use of MI underestimates engagement, retention
and viral suppression (VS) among MSM compared to analysis without MI in Georgia
• This underestimation is greater in groups with a smaller N (e.g., Hispanic/Latino MSM by age)
• Among males, MI overestimates engagement, retention and viral suppression by 1-2% points for IDU, HET and MSM/IDU males
• Among females, MI overestimates engagement, retention and viral suppression by 0-4% points for both IDU and HET
Limitations• Cannot assess the validity of assumptions made in
MI• The pattern of risk factors has changed since the
beginning of the epidemic• Cases missing risk may be fundamentally different
from those for whom risk is reported.• Results for smaller subgroups may differ
statistically with or without use of MI• Under- and overestimates found using MI in the
Georgia 2012 prevalent population are not generalizable to new diagnoses or to future years’ analyses
• Despite limitations, MI is considered by CDC to be the best currently available method to adjust for missing (not reported) risk factor information
References• Barnard J, Meng XL. Applications of multiple
imputation in medical studies: from AIDS to NHANES. Stat Methods Med Res. 1999 Mar;8(1):17-36
• Harrison KM, Kajese T, Hall HI, Song R. Risk factor redistribution of the national HIV/AIDS surveillance data: an alternative approach. Public Health Rep 2008;123:618–27
• Rubin DB. Multiple imputation for nonresponse in surveys. New York: John Wiley & Sons; 1987