Dr. Kathleen Brady (AACO)'s epidemiologic update as presented to the Philadelphia Prevention Planning Group (PPG) on Wednesday, March 27, 2013.

1. The HIV Engagement in Care
Cascade
KATHLEEN A. BRADY, MD
MEDICAL DIRECTOR/MEDICAL
EPIDEMIOLOGIST
AIDS ACTIVITIES COORDINATING OFFICE
MARCH 27, 2013

2. The Gardner Cascade

3. Engagement in Care

4. Gardner Stage of Engagement in HIV Care

5. Gardner Stage of Engagement in HIV Care
19%
undetectable

6. 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

7. 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

8. 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.

9. 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

10. 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

12. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

13. For every 100 people living with HIV:
US Philadelphia
Number Number
Are aware of their Are aware of their
82 82
infection infection
66 Are linked to HIV care 62 Are linked to HIV care
37 Stay in HIV care 52 Stay in HIV care
Get antiretroviral Get antiretroviral
33 46
therapy therapy
Have a very low amount Have a very low amount
25 30
of virus in their body of virus in their body
2009 Data

14. Who is Aware?

15. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

18. HIV Prevalence in Philadelphia
(reported thru 6/30/2012)
 19,157 PLWHA (aware)  Rates (known) vary by
 11,583 AIDS cases race
 7,574 HIV cases  2.1% of blacks
 4,205 estimated to be  1.5% of Latinos
living with HIV and  0.7% of whites
unaware  Rates vary by sex
 1.59% Philadelphia  1.9% of males
residents estimated to be  0.7% of females
HIV+

19. HIV Prevalence in Philadelphia EMA
(reported thru 6/30/2012)
 25,968 PLWHA (aware)  Rates (known) vary by
 15,178 AIDS cases race
 10,790 HIV cases  1.4% of blacks
 5,700 estimated to be  0.9% of Latinos
living with HIV and  0.2% of whites
unaware  Rates vary by sex
 0.5% Philadelphia EMA  0.7% of males
residents estimated to be  0.3% of females
HIV+

20. HIV/AIDS Cases by Date of Diagnosis
AIDS HIV
1400 1308 1302
1178 1177 1200
1200 1001
Number of Cases
898 894 895 907 861 940 918 921 893
1000 821
712 756 729 712
800 652
600 452
400 221 239
176
200
0
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
11
19
19
19
19
19
19
19
20
20
20
20
20
20
20
20
20
20
20
20
Year
20

21. HIV/AIDS Cases by Sex and Date of
Diagnosis
AIDS Female AIDS Male HIV Female HIV Male
1600
1400
Number of Cases
1200
1000
800
600
400
200
0
91
93
95
97
99
01
03
05
07
09
11
19
19
19
19
19
20
20
20
20
20
20
Year
21

22. HIV Cases by Race/Ethnicity and Date of
Diagnosis
White AfrAm Hispanic
700
575 594
600 534
498
Number of Cases
479
500
400
300
171
200 142 127
210 106 110
100 133 146 127
95
0
2006 2007 2008 2009 2010 2011
Year
22

23. HIV diagnoses by risk group, 2007-2011
600
500
400
300
200
100
0
2007 2008 2009 2010 2011
MSM IDU HET

24. Demographics of new positives, MSM
New HIV diagnoses among New HIV diagnoses among
MSM by race, 2007-2011 MSM by age, 2007-2011
70% 60%
60% 50%
50% 40%
40%
30%
30%
20% 20%
10% 10%
0% 0%
Black Latino White 13 - 24 25 - 44 45+

25. Demographics of new positives, MSM youth
New HIV diagnoses among New HIV diagnoses among
MSM youth, 2007-2011 MSM youth, 2007-2011
Race Age
7.6%
12.6%
9.3%
75.4% 92.0%
Black White Latino 13-17 18-24

28. Demographics of new positives, IDU
New HIV diagnoses among New HIV diagnoses among
IDU, 2007-2011 IDU, 2007-2011
Race Age
10.2%
16.0%
44.1% 36.2%
38.0% 53.1%
Black White Latino 13-24 25-44 45+

29. Demographics of new positives, IDU
2007 - 2011
Sex
29.8%
Male
Female
70.1%

31. Demographics of new positives, Heterosexuals
New HIV diagnoses among New HIV diagnoses among
HET, 2007-2011 HET, 2007-2011
Race Age
8.8% 3.8%
15.0% 34.6%
50.6%
72.7%
Black White Latino 13-24 25-44 45+

32. Demographics of new positives, HET
2007 - 2011
Sex
Male
49.2%
Female
50.7%

36. Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMA
EMA Philadelphia PA NJ
Total EMA N=1,606 N=378 N=237
N=2,221 % % % %
Race/Ethnicity
White, non-Hispanic 481 21.7 16.1 38.9 32.1
Black, non-Hispanic 1,313 59.1 64.1 46.8 45.1
Hispanic 372 16.7 17.8 10.0 20.3
Asian/PI 3 0.2 1.2 2.4 2.1
American Indian/Alaskan 4 0.2 0.0
Native 1.5 0.0
Multi-Race 18 0.8 0.6 1.9 0.4
Unknown 0 0.0 0.0 0.0 0.0
Gender
Male 1,634 73.6 73.6 74.6 71.7
Female 587 26.4 26.4 25.4 28.3

37. Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMA
EMA Philadelphia PA NJ
Total EMA N=1,606 N=378 N=237
N=2,221 % % % %
Age
<13 years 13 0.6 .5 0.8 0.8
13 - 19 years 140 6.3 6.4 7.4 3.8
20 - 44 years 1,51 69.8 70.5 6.9 69.6
45+ years 517 23.3 22.5 24.9 25.7
Mode of Transmission
Men who have sex with men 840 37.8 39.5 29.9 38.8
Injection drug users 222 10.0 9.5 14.6 6.3
Men who have sex with men 50 2.3 2.2 2.9 1.3
and inject drugs
Heterosexuals 813 36.6 35.4 36.0 46.0
Other/Hemophilia/blood 0 0.0 0.0 0.0 0.0
transfusion
Perinatal Exposure 18 0.8 0.6 1.9 0.8
Risk not reported or identified 192 8.6 9.5 10.1 0.8

38. Newly diagnosed HIV (Non-AIDS) for 2009-2011 for the Philadelphia EMA
EMA Philadelphia PA NJ
Total EMA N=1,606 N=378 N=237
N=2,221 % % % %
Insurance
Medicaid 411 18.5 23.1 0.0 16.9
Private 414 18.6 21.9 0.0 26.6
No Coverage 167 7.5 7.7 0.0 18.1
Other Public Funding 305 13.7 18.4 0.0 3.8
Unknown 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 increasing
 Growing numbers of persons living with HIV and
AIDS
 25% decline in newly diagnosed AIDS
39

40. Who is unaware?

41. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

42. Concurrent HIV/AIDS, 2010

43. Concurrent HIV/AIDS, 2010

44. Linkage to care

45. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

46. Linkage to Care 2009-2010
by Age, Race
85%
81%
80% 79%
76%
76%
75%
75% 74% 73%
72%
70%
68%
65%
60%
Total 13-24 25-34 35-44 45-54 55+ Black Hispanic White

47. Linkage to Care 2009-2010
by Sex, Mode
90%
81%
80% 75%
74% 73% 74%
72%
68% 69%
70%
60%
50%
43%
40%
30%
20%
10%
0%
Total Male Female MSM Male IDU Male HET Male Female IDU Female HET
MSM/IDU

48. Retention in care

49. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

50. 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

51. 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

52. Population Sizes
Population Sizes Value Data Source(s)
Row A. Number of persons living 11,569 Local eHARS data
with AIDS (PLWA), for (15,178) (EMA data)
the period of
12/31/2011
Row B. Number of persons living 7,523 Local eHARS data
with HIV (PLWH)/non- (10,090) (EMA data)
AIDS/aware, for the
period of 12/31/2011
Row C. Total number of 19,092 Local eHARS data
HIV+/aware for the (25,968) (EMA data)
period of 12/31/2011

53. Care Patterns Value Data Source(s)
Row D. Number of PLWA 9,948 Surveillance Data
who received the (13,053) (Lab Data),
specified HIV CAREWare
primary medical (EMA data)
care during the
12-month period
of 2011
Row E. Number of 5,132 Surveillance Data
PLWH/non-AIDS (7,370) (Lab Data)
who received the CAREWare
(EMA data)
specified HIV
primary medical
care during the
12-month period
of 2011

54. Row F. Total number of 15,080
HIV+/aware who (20,423)
received the
specified HIV
primary medical
care during the 12-
month period of
2011

55. Calculated Results Value Calculation
Row G. Number of PLWA who 1,621 =A–D
did not receive primary (2,125) (EMA data)
medical services during (14.0%)
the 12-month period of
2011
Row H. Number of PLWH/non- 2,391 =B–E
AIDS who did not receive (3,420) (EMA data)
primary medical services (31.8%)
during the 12-month
period of 2011
Row I. Total of HIV+/aware not 4,012 =G+H
receiving specified (5,545) (EMA data)
primary medical care (21.0%)
services (quantified
estimate of unmet need

56. Unmet need by demographic groups, 2011
40.0% 40.0%
35.0% 35.0% 33.4%
31.8%
33.6%
30.0% 27.4% 30.0% 28.1%
25.0% 25.0%
20.0% 20.0%
15.5% 15.2%
15.0% 15.0%
15.2% 10.6%
10.0% 13.4% 10.0%
5.0% 5.0%
0.0% 0.0%
HIV AIDS HIV AIDS
Black White Hispanic Male Female

57. Unmet need by insurance status, 2011
50.0% 46.4%
45.0% 43.1%
40.0%
35.0% 33.7%
28.3% 29.6%
30.0% 26.6%
25.0% 22.4%
20.0%
15.0% 13.5%12.6%
10.0% 7.5%
5.0%
0.0%
HIV AIDS
Medicaid Private Other public Unknown None

58. Disparities

59. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

61. Engagement in Care by Sex, 2009
Male Female
12000 82% 6000
10000 5000 82%
8000 4000 67%
47% 54%
43%
6000 3000
35%
35%
4000 2000
2000 1000
0 0

63. Engagement in Care by Race/Ethnicity, 2009
12000
82%
10000
8000
49%
6000 42%
31%
4000 82%
54%50%45% 82%68%
2000 60%
39%
0
Black White Hispanic
Diagnosed In Care On ART Suppressed

65. Engagement in Care by Mode of
Transmission, 2009
6000
82%
82%
5000 4668
4000 64%
49%
46% 48% 51%
3000 39% 43%
32% 33%
2000
1000
0
MSM HET male HET female
Diagnosed In Care On ART Suppressed

67. Engagement in Care by Age Group, 2009
6000
5000
4000
3000
2000
1000
0
18-24 25-34 35-44 45-54 55+
Diagnosed In Care On ART Suppressed

68. 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

69. Starting Antiretroviral Therapy in 2012: A Compendium of Interactive Cases
clinicaloptions.com/hiv
What Will It Take to Substantially Reduce
HIV Transmission in an Entire Population?
Undiagnosed HIV
•1,200,000 Not linked to care
Not retained in care
•Number of Individuals
•1,000,000 ART not required
ART not utilized
•800,000 Viremic on ART
Undetectable
•600,000 HIV-1 RNA
•400,000 •66%
•200,000 •34% •28%
•19% •22% •21%
•0
•Current •DX •Engage •Treat •VL < 50 •Dx,
90% 90% 90% in 90% Engage, Tx,
and VL < 50
in 90%
•Answer: Treatment AND Prevention
•Gardner EM, et al. Clin Infect Dis. 2011;52:793-800.

70. The End
QUESTIONS?